View source for Affordable Care Act

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{{Infobox U.S. legislation
| enacted by = 111th
| effective date = {{start date and age|2010|3|23}}<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020; penalty enforcing individual mandate 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]] ([[Democratic Party (United States)|D]]–[[New York (state)|NY]])
| introduceddate = September 17, 2009
| committees = [[United States House Committee on Ways and Means|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 = [[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 = 
}}
{{Barack Obama sidebar}}
The '''Patient Protection and Affordable Care Act''' ('''PPACA'''), often shortened to the '''Affordable Care Act''' ('''ACA''') or nicknamed '''Obamacare''', is a United States [[U.S. federal law|federal statute]] enacted by the [[111th United States Congress]] and signed into law by [[President of the United States|President]] [[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 (United States)|Medicare]] and [[Medicaid]] in 1965.<ref name="Oberlander2010"/><ref name="Blumenthal2015"/><ref name="CohenEtAl"/><ref name="ReutersSCOTUS"/>

The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered during 2016.<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}}</ref> The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to major changes to [[Individually purchased health insurance|individual insurance]] markets. Both involved new spending, funded through a combination of new taxes and cuts to Medicare provider rates and [[Medicare Advantage]]. Several [[Congressional Budget Office]] reports said that overall these provisions reduced the [[Government budget balance|budget deficit]], that repealing the ACA would increase the deficit,<ref name="CBO50252"/><ref name="CBO22077"/> and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.<ref name="CBO_Dist14"/> The law also enacted a host of [[Healthcare industry#Delivery of services|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/>

The act largely retains the existing structure of Medicare, Medicaid, and the [[Health insurance in the United States#Employer sponsored|employer market]], but individual markets were radically overhauled around a three-legged program.<ref name="Oberlander2010"/><ref name="Gruber2011">{{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=23 July 2017 |doi=10.17310/ntj.2011.3.06|hdl=1721.1/72971 }}</ref> Insurers in these markets are made to [[Guaranteed issue|accept all applicants]] and [[Community rating|charge the same rates]] regardless of [[pre-existing condition]]s or sex. To combat resultant [[adverse selection]], the act [[Individual shared responsibility provision|mandates]] that individuals buy insurance and insurers cover a list of "[[essential health benefits]]". The [[Tax Cuts and Jobs Act of 2017]] zeroed out the federal tax penalty for violating the individual mandate, starting in 2019. (In order to pass the Senate under [[Reconciliation (United States Congress)|reconciliation rules]] with only 50 votes, the requirement itself is still in effect.)<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> To help households between 100–400% of the [[Poverty in the United States#Recent poverty rate and guidelines|Federal Poverty Line]] afford these compulsory policies, the law provides [[premium tax credit|insurance premium subsidies]]. Other individual market changes include [[health insurance marketplace|health marketplaces]] and [[Risk equalization|risk adjustment]] programs.

Since being signed into law in 2010, the PPACA has faced strong political opposition, calls for repeal (from [[Republican Party (United States)|Republicans]]) and numerous [[Constitutional challenges to the Patient Protection and Affordable Care Act|legal challenges]]; its enactment is considered to be a catalyst for the [[Tea Party movement]]. In ''[[National Federation of Independent Business v. Sebelius]]'', the [[Supreme Court of the United States|Supreme Court]] ruled that states could choose not to participate in the ACA'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. In 2017, a unified [[Republican Party (United States)|Republican]] government attempted but failed to pass [[American Health Care Act of 2017|several different]] partial repeals of the ACA. The law spent several years opposed by a slim [[Plurality (voting)|plurality]] of Americans polled, although its provisions were generally more popular than the law as a whole,<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=23 July 2017 |date=1 December 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=18 November 2017 |work=The Hill |language=en}}</ref>{{TOC limit|3}}

== Outline of Coverage Mechanism ==
An intent of the ACA is to make coverage available to all, regardless of whether they have pre-existing health conditions, at an affordable cost. This is done by (for the case of U.S. citizens<ref>{{Cite web|url=https://www.healthcare.gov/immigrants/lawfully-present-immigrants/#targetText=Lawfully%20present%20immigrants%20and%20Marketplace%20savings&targetText=You%20may%20be%20eligible%20for,other%20savings%20on%20Marketplace%20insurance.|title=Health coverage for lawfully present immigrants|website=HealthCare.gov|language=en|access-date=2019-08-24}}</ref><ref name=":8" />):

# Expanding employer coverage through the [[Patient Protection and Affordable Care Act#Employer mandate|Employer mandate]],
# Retaining existing [[Medicaid]] programs ("traditional Medicaid"; which generally required both low incomes and very low asset levels), and also [[Children's Health Insurance Program|Children's Health Insurance Programs (CHIPs)]],
# Starting a new class of [[Medicaid]], [[Patient Protection and Affordable Care Act#Medicaid expansion|expanded Medicaid,]]  for people whose Modified Adjusted Gross Incomes (MAGIs) are no more than 138% of the Federal Poverty Level (FPL)<ref name=":4">{{Cite web|url=https://www.payingforseniorcare.com/longtermcare/federal-poverty-level.html|title=2019 Federal Poverty Guidelines / Federal Poverty Levels|website=www.payingforseniorcare.com|access-date=2019-08-10}}</ref> and with no maximum asset levels<ref>{{Cite web|url=https://www.healthinsurance.org/glossary/medicaid-expansion/|title=Medicaid expansion definition|date=2018-11-19|website=healthinsurance.org|language=en|access-date=2019-08-10}}</ref>,
#[[Patient Protection and Affordable Care Act#Insurance_regulations:_individual_policies|Requiring individual major medical policies]] from private insurers to accept all people regardless of pre-existing conditions, and to not consider pre-existing conditions in rates charged. Rates may vary depending on age, but the maximum ratio of premiums for the oldest to the youngest covered are capped at 3 to 1<ref name=":45" />. (The ACA attempted to be make the policies provide strong coverage by requiring essential benefits, and by not allowing yearly or lifetime caps on coverage, as well as having maximum annual out-of-pocket payment caps.)
# For people who do not have coverage available by other means (an affordable employer's or a family member's employer insurance program, or the items in (2) and(3) above: a traditional Medicaid or expanded Medicaid or a CHIP or other public assistance health coverage), if their MAGIs are from 100% to 400% of the FPL<ref name=":4" />, [[Patient Protection and Affordable Care Act#Subsidies|sliding-scale income-based subsidies]] are provided<ref name=":8">{{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=2018-11-20|website=The Henry J. Kaiser Family Foundation|language=en-us|access-date=2019-08-10}}</ref>.

Essentially, for people without employer insurance, if incomes are through 138% of the FPL, the ACA design intends all people either get Medicaid coverage, or expanded Medicaid coverage. For the remaining individuals, a major medical policy will be available, with a sliding-scale subsidy for individuals with incomes below 400% FPL, to attempt to make the policy affordable.

Part of the mechanism was also from a mandate to carry coverage (or else pay a penalty).  This was designed to keep insurance costs lower than they would otherwise be, by limiting [[adverse selection]] due people just picking up insurance when they got sick, or if they were more likely to get sick.

It should be noted that, while the intent of the ACA's design was to provided affordable coverage to all, it was not designed to lower premiums for all people.  Certain individuals were expected to pay higher, but still affordable, premiums, compared to what they would have without the ACA.  A specific case of this would be people who had no pre-existing conditions, and might have, without the ACA, been able to purchase pre-existing-condition-screened insurance at a low premium, made possible by the fact that the pool of people insured by the policy had few sick people in it.  The ACA, by requiring people with pre-existing conditions also to be covered by all plans at the same premium, would yield higher raw (before-subsidy) policy premiums for the people without pre-existing conditions. In the case where incomes were greater than 400% of the FPL, there is no subsidy under the ACA, so the post-ACA premiums that have to be paid by the individual  would be higher. However, the theory would be that, did those same people need insurance when they had serious pre-existing conditions, they would often then be better off post ACA.  For example, in 2012 (the next to the last year before the main ACA provisions went into effect) in Connecticut, the only alternative for individual insurance coverage for people with substantial pre-existing conditions would have been the high-risk-pools, which had rates as high as as $2077.18 a month per person (male 60 to 64) for $7500 out-of-pocket-maximum coverage,<ref>{{Cite web|url=https://web.archive.org/web/20120606085707/http://www.hract.org/hra/Rates/2012/Individual/IndPPORates.htm|title=Health Reinsurance Association|date=2012-06-06|website=web.archive.org|access-date=2019-08-25}}</ref> and $3908.02 a month for the $1000 out-of-pocket-maximum coverage<ref>{{Cite web|url=https://web.archive.org/web/20120429071912/http://www.hract.org/hra/Rates/2012/Individual/IndSHCPRates.htm|title=Health Reinsurance Association|date=2012-04-29|website=web.archive.org|access-date=2019-08-25}}</ref> (same male 60 to 64 in the ACA-unsubsidized income-greater-than-400%-FPL case). 

'''Impediments and Imperfections to Design:'''

While provisions (4) for individual major medical policies are designed to make them strong policies with good coverage, other coverage post-ACA may not be so strong.

Large group employer policies are not regulated by the ACA, and may provide weaker coverage.

In addition,  in certain states, coverage under the traditional Medicaid and expanded Medicaid programs is subject to [[Medicaid estate recovery]] of all medical expenses that were paid out for a person while they had Medicaid or expanded Medicaid.  The recovery is from a person's estate when they die, and applies only if they were 55 or older when they had the coverage<ref name=":5">{{Cite web|url=https://www.medicaid.gov/medicaid/eligibility/estate-recovery/index.html|title=Estate Recovery and Liens|website=www.medicaid.gov|language=en-us|access-date=2019-08-10}}</ref> <ref name=":6">{{Cite web|url=https://www.elderlawanswers.com/medicaids-power-to-recoup-benefits-paid-estate-recovery-and-liens-12018|title=Medicaid's Power to Recoup Benefits Paid: Estate Recovery and Liens|website=ElderLawAnswers|language=en|access-date=2019-08-10}}</ref> <ref name=":7">{{Citation|title=Medicaid estate recovery|date=2019-08-09|url=https://en.wikipedia.org/enwiki/w/index.php?title=Medicaid_estate_recovery&oldid=910009004|work=Wikipedia|language=en|access-date=2019-08-10}}</ref> (Individuals who are eligible for Medicaid or expanded Medicaid are not eligible to receive the subsidies described in (5) above. They can avoid the estate recovery, by purchasing the major medical policies described in (4), without a subsidy, subject to whether they can afford it.)

In a 2012 Supreme Court decision<ref>{{Citation|title=National Federation of Independent Business v. Sebelius|date=2019-08-16|url=https://en.wikipedia.org/enwiki/w/index.php?title=National_Federation_of_Independent_Business_v._Sebelius&oldid=911012253|work=Wikipedia|language=en|access-date=2019-08-20}}</ref>, it was made optional for states to expand Medicaid, rather than mandatory, as intended. This has resulted in a coverage gap for many of those who were intended to covered by expanded Medicaid<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|last=Orgera|first=Kendal|last2=Mar 21|first2=Anthony Damico Published:|date=2019-03-21|website=The Henry J. Kaiser Family Foundation|language=en-us|access-date=2019-08-20|last3=2019}}</ref>.

Many states which have expanded Medicaid have, since 2014, have sought and received Federal waivers to add work-requirements for the receipt of Medicaid and expanded Medicaid, which interfere with the original intent.<ref>{{Cite web|url=https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/|title=Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State|last=Aug 09|first=Published:|last2=2019|date=2019-08-09|website=The Henry J. Kaiser Family Foundation|language=en-us|access-date=2019-08-20}}</ref>

Removal of the mandate to carry coverage (effective in 2019<ref name=":30" />) may increase increase adverse selection in states which do not have their own mandate to carry coverage, increasing costs of individual major medical policies, particularly for those not eligible for the ACA's federal subsidies.

== Specific Provisions ==
<br />{{See also|Provisions of the Patient Protection and Affordable Care Act}}
[[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 celebrating after the House passes the amended bill on March 21]]
The ACA includes provisions taking effect from 2010 to 2020, although most took effect on January 1, 2014. It amended the [[Public Health Service Act of 1944]] and inserted new provisions on affordable care into [[Title 42 of the United States Code]].{{citation needed|date=December 2017}} Few areas of the US health care system were left untouched, making it the most sweeping health care reform since the [[Social Security Amendments of 1965|enactment]] of [[Medicare (United States)|Medicare]] and [[Medicaid]] in 1965.<ref name="Oberlander2010">{{cite journal |last1=Oberlander |first1=Jonathan |title=Long Time Coming: Why Health Reform Finally Passed |journal=Health Affairs |date=1 June 2010 |volume=29 |issue=6 |pages=1112–1116 |doi=10.1377/hlthaff.2010.0447 |pmid=20530339 |language=en |issn=0278-2715 |df=mdy-all }}</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=18 June 2015 |volume=372 |issue=25 |pages=2451–2458 |doi=10.1056/NEJMhpr1503614 |pmid=25946142 |issn=0028-4793}}</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=1 June 2015 |publisher=Oxford University Press |isbn=9780190231569 |url=https://books.google.com/books?id=H9DGBwAAQBAJ |language=en}}</ref><ref name="NYTsigning">{{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=23 March 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=28 June 2017}}</ref> However, some areas were more affected than others. 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 [[Health insurance in the United States#Employer sponsored|employer market]] were largely retained.<ref name="Blumenthal2015"/> Most of the coverage gains were made through the expansion of Medicaid,<ref>{{cite news |last1=Greenberg |first1=Jon |title=Rand Paul goes too far on Obamacare Medicaid growth |url=http://www.politifact.com/truth-o-meter/statements/2017/jan/15/rand-paul/medicaid-expansion-drove-health-insurance-coverage/ |work=politifact |date=15 January 2017 |language=en}}</ref> and the biggest cost savings were made in Medicare.<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"/> Not all provisions took full effect. Some were made discretionary, some were deferred, and others were repealed before implementation.

=== Insurance regulations: individual policies ===
The following applies to all new individual major medical health insurance policies sold to individuals and families (whether offered on an ACA exchanges, or off exchange), and referred to generally as ACA-compliant plans.<ref>{{Cite web|url=https://www.healthinsurance.org/glossary/aca-compliant-coverage/|title=ACA-compliant coverage definition|date=2016-05-12|website=healthinsurance.org|language=en|access-date=2019-08-10}}</ref> 

The requirements began Jan 1, 2014.

* [[Guaranteed issue]] prohibits insurers from denying coverage to individuals due to [[pre-existing condition]]s. States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
* Premiums must be the same for everyone of a given age, regardless of preexisting conditions. Premiums are allowed to vary by enrollee age, but those for the oldest enrollees (age 45–64, average expenses $5,542) can only be three times as large as those for adults 18–24 ($1,836).<ref>{{cite web |last1=Amadeo |first1=Kimberly |title=How Much Will Obamacare Cost Me |url=https://www.thebalance.com/how-much-will-obamacare-cost-me-3306054 |website=The Balance |accessdate=November 11, 2016}}</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="FamiliesUSABOR" /><ref name=naic.org/><ref name=Hhs.gov/><ref name=essential/><ref name=CohnInsuranceStandards/><ref name=KaiserEHB/><ref name=hcgess/> 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 [http://www.ahrq.gov/clinic/pocketgd1011/gcp10s1.htm Level A or B] by the [[United States Preventive Services Task Force|U.S. Preventive Services Task Force]].<ref name=ReferenceB/> In determining what would qualify as an essential benefit, the law required that standard benefits should offer at least that of a "typical employer plan".<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>
* Additional preventive care and screenings for women.<ref>[https://www.govtrack.us/congress/bills/111/hr3590/text PPACA], 2713,(a)(4)</ref> The guidelines issued by the [[Health Resources and Services Administration]] to implement this provision mandate "[a]ll Food and Drug Administration approved [[contraception|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, US 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 & Affodable 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/>
* Prohibits insurers from dropping [[policyholder]]s when they get sick.<ref name="Top 18" />
* All health policies sold in the United States 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 cap 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>
* A partial [[community rating]] requires insurers to offer the same premium to all applicants of the same age and location without regard to gender or most pre-existing conditions (excluding [[tobacco]] use).<ref name=75FR37187/><ref name=Pool/><ref name=Nursingworld.org/> Premiums for older applicants can be no more than three times those for the youngest.<ref name=":45">{{cite web |title=Age Band Rating (ACA) |publisher=[[National Association of Personal Financial Advisors]] |url=http://www.naifa.org/practice-resources/prp/age-band-rating-(aca)}}</ref>
* Preventive care, vaccinations and medical screenings cannot be subject to [[Copayment|co-payments]], [[Co-insurance#In health insurance|co-insurance]] or [[Deductible#Health and travel insurance|deductibles]].<ref name=SHNS/><ref name=KaiserSummary/><ref name=cmsprev/> Specific examples of covered services include: [[mammograms]] and [[Colonoscopy|colonoscopies]], wellness visits, [[gestational diabetes]] screening, [[human papillomavirus|HPV]] testing, [[sexually transmitted infection|STI]] counseling, [[human immunodeficiency virus|HIV]] screening and counseling, contraceptive methods, breastfeeding support/supplies and [[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 prices in the United States|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 [[appeal]]s process for coverage determination and claims on all new plans.<ref name="Top 18" />
* Insurers must [[Loss ratio#Medical loss ratio|spend at least 80–85% of premium dollars]] on health costs; rebates must be issued to [[policyholder]]s if this is violated.<ref name=cmsprog/><ref name=FederalRegister/>

===Individual mandate===
The [[Health insurance mandate#Affordable Care Act|individual mandate]]<ref name=AHPAMandate/> was the requirement to buy insurance or [[Provisions of the Patient Protection and Affordable Care Act#Effective January 1, 2014|pay a penalty]] for everyone not covered by an [[Employer-sponsored health insurance|employer sponsored health plan]], [[Medicaid]], [[Medicare (United States)|Medicare]] or other public insurance programs (such as [[Tricare]]). Also exempt were those facing a financial hardship or who were members in a recognized religious sect exempted by the [[Internal Revenue Service]].<ref name=ksr_hlth/>

The mandate and the limits on open enrollment<ref name=CohnOE/><ref name=LimitedOEForbes/> were designed to avoid the [[Death spiral (insurance)|insurance death spiral]] in which healthy people [[Free rider problem|delay insuring themselves until they get sick]]. In such a situation, insurers would have to raise their premiums to cover the relatively sicker and thus more expensive policies,<ref name=AHPAMandate/><ref name=ReformWithoutTheMandate/><ref name=man1/> which could create a [[Virtuous circle and vicious circle|vicious cycle]] in which more and more people drop their coverage.<ref>{{cite news |url=https://newrepublic.com/article/113851/obamacare-individual-mandate-republicans-push-delay |title=Obamacare's Individual Mandate Can't Wait |last=Cohn |first=Jonathan |date=July 15, 2013 |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}}</ref>

The purpose of the mandate was to prevent the healthcare system from succumbing to [[adverse selection]], which would result in high premiums for the insured and little coverage (and thus more illness and medical bankruptcy) for the uninsured.<ref name=ReformWithoutTheMandate/><ref name=NRCohnNJ/><ref name=jic/> Studies by the [[Congressional Budget Office|CBO]], [[Jonathan Gruber (economist)|Gruber]] and Rand Health concluded that a mandate was required.<ref name=man2/><ref name=GruberMandate/><ref name=randaff/> The mandate increased the size and diversity of the insured population, including more young and healthy participants to broaden the [[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> Experience in New Jersey and Massachusetts offered divergent outcomes.<ref name=NRCohnNJ/><ref name=GruberMandate/><ref name=cohnman/>

Among the groups who were not subject to the individual mandate are:
* [[Illegal immigrant population of the United States|Illegal immigrants]], estimated at around 8 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.
* Eligible citizens not enrolled in Medicaid.<ref name=notcovered/>
* Citizens who pay the annual penalty instead of purchasing insurance, mostly younger and single.<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 [[Medicaid coverage gap|states that opt out of the Medicaid expansion]] and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.<ref name="optout" />
* All citizens as of December 20, 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|first=Orrin|last=Hatch|date=December 20, 2017|accessdate=December 21, 2017|publisher=[[Fox News]]}}</ref>

On December 20, 2017, President Trump signed into law the [[Tax Cuts and Jobs Act of 2017]],<ref name="hatchsays" /> which zeroed out the federal tax penalty for violating the individual mandate, starting in 2019. (In order to pass the Senate under [[Reconciliation (United States Congress)|reconciliation rules]] with only 50 votes, the requirement itself is still in effect).<ref name="auto"/>

===Premium Subsidies===
Individuals whose household incomes are between 100% and 400% of the [[federal poverty level]] are eligible to receive [[subsidy|federal subsidies]] applied towards premiums for policies purchased via an exchange, provided they are not eligible for [[Medicare (United States)|Medicare]], [[Medicaid]] (including the ACA's expanded Medicaid), the [[Children's Health Insurance Program]], or other forms of public assistance health coverage, and provided also they do not have access to affordable (currently no more than 9.86% MAGI for ''just the employee's coverage'') 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 federal subsidies. (Except, lawfully present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for tax subsidies if they meet all other eligibility requirements<ref>{{Cite web|url=https://www.healthcare.gov/immigrants/lawfully-present-immigrants/#targetText=Lawfully%20present%20immigrants%20and%20Marketplace%20savings&targetText=You%20may%20be%20eligible%20for,other%20savings%20on%20Marketplace%20insurance.|title=Health coverage for lawfully present immigrants|website=HealthCare.gov|language=en|access-date=2019-08-24}}</ref><ref name="KaiserFamily" />.)  Married individuals must file taxes jointly in order to receive federal subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.

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

The amount of subsidy is calculated to make the second lowest cost silver plan (SCLSP) on the exchange cost a sliding-scale percentage of  Modified Adjusted Gross Income (MAGI).  The sliding-scale percentage is based on the percent of Federal Poverty Level (FPL) for the household, and varies slightly from year to year. In 2019, it ranges from 2.08% of MAGI (100%-133% FPL) to 9.86% of MAGI (300%-400% FPL), outside of Alaska and Hawaii.<ref name="hip-dhhs" />

The requirement to get a subsidy, do not have access to affordable (currently no more than 9.86% MAGI for ''just the employee's coverage'') employer coverage may leave a family with no option for affordable coverage.  That is, the employer coverage for the ''whole family,'' could be, say, 25% of MAGI, making it unaffordable.  This issue is called the ''family glitch''.<ref name=":27">{{Cite web|url=https://khn.org/news/fixing-obamacares-family-glitch-hinges-on-outcome-of-november-elections/|title=Fixing Obamacare's 'Family Glitch' Hinges On Outcome Of November Elections|last=Luthra|first=Shefali|date=2018-10-23|website=Kaiser Health News|language=en-US|access-date=2019-08-13}}</ref>

Additionally, small businesses are eligible for a tax credit provided that they enroll in the [[Small Business Health Options Program|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=":8" />
|-
! Income % of [[federal poverty level]]
! Premium Cap as a Share of MAGI Income
! Income{{ref|fedpovlevel|a}}(MAGI)
! Maximum Annual Net Premium After Subsidy
(Second Lowest Cost Silver Plan)
|-
| 133%
| 3.11% of income
| $33,383
| $1,038
|-
| 150%
| 4.15% of income
| $37,650
| $1,562
|-
| 200%
| 6.54% of income
| $50,200
| $3,283
|-
| 250%
| 8.36% of income
| $62,750
| $5,246
|-
| 300%
| 9.86% of income
| $75,300
| $7,425
|-
| 400%
| 9.86% of income
| $100,400
| $9,899
|-
| colspan="4" style="text-align:left; background:white; border-top:1px solid black; padding:0 1em;" |
<small>a.{{note|fedpovlevel}}Note: In 2019, the Federal Poverty Level was $25,100 for family of four.</small><ref name=":8" />
|}

=== Cost-sharing Reductions ===
Separate from premium subsidies, people eligible for premium subsidies, who, in addition, have Modified Adjusted Gross Incomes (MAGIs) between 100% and 250% of the Federal Poverty Level (FPL), receive also, if they purchase silver plans, cost-sharing reductions (CSRs) on their policies. This means the policies have reduced out-of-pocket maximums, and the policies must have increased actuarial values, which tend to give them reduced copayments compared to policies without cost-sharing reductions<ref name=":42">{{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=2018-11-20|website=The Henry J. Kaiser Family Foundation|language=en-US|access-date=2019-08-25}}</ref>.

The reduced out-of-pocket maximums, and increased actuarial values, are on a sliding scale.  

For 2019, silver plans normally have a maximum copay of $7900 / $15,800 (individual/family), and have a required actuarial coverage value of 70%.  For for individuals with MAGIs of 100-150% MAGI, the maximum copay is $2,600 / $5,200, and the required actuarial coverage is 94%. For individuals with MAGIs of 200-250% MAGI, the maximum copay is $6,300 / $12,600, and the required actuarial coverage is 73%.<ref name=":42" />

Before 2018, cost-sharing-reductions were funded directly by payments of the Federal government to insurers, so that the cost of silver plans did not need to be higher than what they would have been without cost-sharing reductions.

President Trump, by executive action on October 12, 2017,<ref name=":43" />  ended the direct payment by the Federal governments to insurers, effective Jan 1, 2018.  At the time of action, it was observed that this would necessitate the raising of premiums on at least some health plans, and possibly all plans.

However, many states reacted to the loss of the Federal payments to insurers by either directing, or allowing, insurance companies to assess the actuarial costs of the lost Federal CSR payments to silver plans only, or sometimes, to silver plans purchased on the exchange only<ref name=":29" /><ref name=":28" />. (The practice was called "silver loading".) 

Where there is silver loading, the effect is to often give people who received premium subsidies who purchased silver plans, roughly the same net-of-premium-subsidy costs as before the Federal payments were stopped. (This is because premium subsides are determined by a formula to make the second lowest cost silver plan cost a certain fixed percentage of MAGI, so that the increased premiums were accompanied by a commensurately increased subsidy.)

Further, where there is silver loading, premiums for bronze, gold, and platinum plans are unchanged.  (So a person not receiving a subsidy could avoid increased costs by avoiding silver plans.) 

(Note that it may be possible for a Presidential administration to ban silver loading in the future, so in that case, the consequences of the lost CSR payments would be more severe.<ref name=":28" />)

It should also be noted in the cases of states or insurers who did not do silver loading, the cost of all plans will increase, and this will yield increased costs to those who receive no premium subsidy

Cost-sharing reductions are also sometimes called cost-sharing subsidies.<ref>{{Cite web|url=https://www.healthinsurance.org/obamacare/the-acas-cost-sharing-subsidies/|title=The ACA’s cost-sharing subsidies|date=2019-06-21|website=healthinsurance.org|language=en|access-date=2019-08-25}}</ref>

===Exchanges===
Established the creation of [[#Insurance exchanges and the individual mandate|health insurance exchanges]] in all fifty states. The exchanges are regulated, largely online marketplaces, administered by either federal or state government, where individuals and small business can purchase private insurance plans.<ref name=HealthCareGov/><ref name=aphabasics/><ref name=CohnExchanges/>Some exchanges, for example for MA and MN, also are the access point for Medicaid and expanded Medicaid coverage.<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)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6696-ENG|title=MN ACA application (MNSURE, their state exchange)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>

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

===Risk corridor program===
{{over-quotation|section|date=July 2017}}

The risk-corridor program was a temporary risk management device defined under the PPACA section 1342<ref name="CRS_2016_risk_corridor">{{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=[[Congressional Research Service]] |page=6}}</ref>{{rp|1}}
to encourage reluctant insurers into the "new and untested"{{attribution needed|date=July 2017}} ACA insurance market during the first three years that ACA was implemented (2014–2016). For those years the [[Department of Health and Human Services]] (HHS) "would cover some of the losses for insurers whose plans performed worse than they expected. Insurers that were especially profitable, for their part, would have to return to HHS some of the money they earned on the exchanges"<ref name="NEJM_2016_RiskCorridor">{{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}}

According to an article in ''[[Forbes]]'', risk corridors "had been a successful part of the Medicare prescription drug benefit, and the ACA's risk corridors were modeled after Medicare's Plan D."<ref name="Forbes_Rubio_2015">{{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> They operated on the principle that "more participation would mean more competition, which would drive down premiums and make health insurance more affordable"{{attribution needed|date=July 2017}} and "[w]hen insurers signed up to sell health plans on the exchanges, they did so with the expectation that the risk-corridor program would limit their downside losses."<ref name="NEJM_2016_RiskCorridor" />{{attribution needed|date=July 2017}} The risk corridors succeeded in attracting ACA insurers. The program did not pay for itself as planned with "accumulated losses"{{attribution needed|date=July 2017}} up to $8.3 billion for 2014 and 2015 alone. Authorization had to be given so that HHS could pay insurers from "general government revenues".{{attribution needed|date=July 2017}} Congressional Republicans "railed against"{{attribution needed|date=July 2017}} the program as a 'bailout' for insurers. Then-Rep. [[Jack Kingston]] (R-Ga.), on the [[United States House Committee on Appropriations|Appropriations Committee]] that funds the [[United States Department of Health and Human Services|Department of Health and Human Services]] and the Labor Department "[slipped] in a sentence"—Section 227—in the "massive" [[Appropriations bill (United States)|appropriations]] [[Consolidated Appropriations Act, 2014]] (H.R. 3547) that said that no funds in the discretionary spending bill "could be used for risk-corridor payments."{{attribution needed|date=July 2017}} This effectively "blocked the administration from obtaining the necessary funds from other programs"<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=[[The Washington Post]] |date=December 23, 2015 |first=Glenn |last=Kessler}}</ref>{{attribution needed|date=July 2017}} and placed Congress in a potential breach of contract with insurers who offered qualified health plans, under the [[Tucker Act]]<ref name="CRS_2016_risk_corridor" /> as it did not pay the insurers.<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" />

On February 10, 2017, in the [[Moda Health]] v the US Government, Moda, one of the insurers that struggled financially because of the elimination of the risk corridor program, won a "$214-million judgment against the federal government".{{attribution needed|date=July 2017}} On appeal, 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 name="ModaVUS_2017">{{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>

===Temporary reinsurance===
Temporary reinsurance for insurance for insurers against unexpectedly high claims was a program that ran from 2014 through 2016. It was intended to limit insurer losses.{{citation needed|date=August 2016}}

===Risk adjustment===
Of the three risk management programs, only risk adjustment was permanent. Risk adjustment attempts to spread risk among insurers to prevent purchasers with good knowledge of their medical needs from using insurance to cover their costs ([[adverse selection]]). Plans with low actuarial risk compensate plans with high actuarial risk.{{citation needed|date=August 2016}}

===Medicaid expansion===
ACA revised and expanded [[Medicaid]] eligibility starting in 2014. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the [[Poverty line in the United States#Measures of poverty|poverty line]], including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. The federal government paid 100% of the cost of Medicaid eligibility expansion in participating states in 2014, 2015, and 2016; and will pay 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>https://www.hhs.gov/news/press/2013pres/03/20130329a.html</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> The law provides a 5% "income disregard", making the effective income eligibility limit for Medicaid 138% of the poverty level.<ref name=138fpl/>

However, the [[Supreme Court of the United States|Supreme Court]] ruled in ''[[National Federation of Independent Business v. Sebelius|NFIB v. Sebelius]]'' that this provision of the ACA was coercive, and that the federal government must allow states to continue at pre-ACA levels of funding and eligibility if they chose.

Expanded Medicaid (as well as the traditional Medicaids that existed prior to the ACA and continue to exist) are subject to [[Medicaid estate recovery]] for people 55 or older in many states. What can be recovered is all medical expenses that were paid out for a person while they had Medicaid or expanded Medicaid.  The recovery is from a person's estate when they die, and applies only if they were 55 or older when they had the coverage<ref name=":5" /> <ref name=":6" /> <ref name=":7" /> . Some states amended laws and regulations since the passage of the ACA to stop the recovery as it relates to ordinary medical insurance coverage (that is, non-long-term-care related coverage),<ref name=":11">{{Cite web|url=https://www.health.ny.gov/health_care/medicaid/publications/gis/14ma016.htm|title=GIS 14 MA/016: Long Term Care Eligibility Rules and Estate Recovery Provisions for MAGI Individuals|website=www.health.ny.gov|access-date=2019-08-10}}</ref><ref name=":12">{{Cite web|url=https://ctmirror.org/2014/04/09/ct-scales-back-medicaid-repayment-rules-for-some-recipients/|title=CT scales back Medicaid repayment rules for some recipients|date=2014-04-09|website=The CT Mirror|language=en-US|access-date=2019-08-10}}</ref><ref name=":13">{{Cite web|url=https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/CT/CT-14-022.pdf|title=CT State Medicaid Plan Amendment 14-022|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name=":14">{{Cite web|url=http://blogs.seattletimes.com/healthcarecheckup/2013/12/16/state-will-change-asset-recovery-policy-for-medicaid-enrollees/|title=State will change asset recovery policy for Medicaid enrollees|last=Ostrom|first=Carol M.|website=The Seattle Times|access-date=2019-08-10}}</ref>,<ref name=":16">{{Cite web|url=https://www.oregonlive.com/finance/2013/12/cover_oregon_state_says_it_won.html|title=Cover Oregon: State says it won't pursue Oregon Health Plan recipients' assets|last=Hunsberger|first=Brent|date=2013-12-02|website=oregonlive.com|language=en-US|access-date=2019-08-10}}</ref><ref name=":17">{{Cite web|url=https://apps.state.or.us/Forms/Served/me9093.pdf|title=Oregon State Medicaid Estate Recovery Document|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name=":18">{{Cite web|url=https://www.mlstargazette.com/story/2017/05/18/news/minnesota-ma-estate-liens-put-to-final-rest/2269.html|title=Minnesota MA estate liens put to final rest|last=Gazette|first=Moose Lake Star|website=Moose Lake Star Gazette|access-date=2019-08-10}}</ref><ref name=":19">{{Cite web|url=https://mn.gov/dhs/people-we-serve/adults/health-care/health-care-programs/programs-and-services/estate-recovery.jsp|title=MN Medicaid Estate Recovery Document|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> <ref name=":21">{{Cite web|url=https://www.hca.wa.gov/health-care-services-supports/program-administration/estate-recovery|title=Estate Recovery {{!}} Washington State Health Care Authority|website=www.hca.wa.gov|access-date=2019-08-10}}</ref><ref name=":22">{{Cite web|url=https://www.mass.gov/files/documents/2019/07/02/aca-1-english-mb.pdf|title=CA Medi-Cal Law Change (2017) Recovery Summary|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>while others have not.<ref name=":23">{{Cite web|url=https://www.mass.gov/files/documents/2019/06/28/aca-3-english.pdf|title=MA ACA application (see (9) and (10) on adobe p. 22)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name=":24">{{Cite web|url=https://www.mass.gov/files/documents/2016/07/ty/130-cmr-515-000.pdf|title=MassHealth General Policies (see 515.011 and 515.012)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> <ref name=":25">{{Cite web|url=https://www.mass.gov/files/documents/2019/07/02/aca-1-english-mb.pdf|title=MassHealth Booklet (describes varieties of Medicaid=MassHealth in MA. Needed for understanding regulations on estate recovery.)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> The issue is controversial<ref>{{Cite web|url=https://www.huffpost.com/entry/beware-of-the-medicaid-bi_b_10185884|title=Beware of the Medicaid 'Big Con'|last=Waldman|first=Deane|last2=ContributorDirector|date=2016-05-31|website=HuffPost|language=en|access-date=2019-08-10|last3=Center|first3=Texas Health Care Policy}}</ref><ref>{{Cite web|url=https://www.paulcraigroberts.org/2014/02/08/obamacare-final-payment-raiding-assets-low-income-poor-americans/|title=Obamacare: The Final Payment--Raiding the Assets of Low-Income and Poor Americans - PaulCraigRoberts.org|website=www.paulcraigroberts.org|language=en-US|access-date=2019-08-10}}</ref><ref>{{Cite web|url=https://www.pbs.org/newshour/show/medicaid-bill-doesnt-go-away-die|title=The Medicaid bill that doesn't go away when you die|date=2015-03-24|website=PBS NewsHour|language=en-us|access-date=2019-08-10}}</ref>.<br />

===Medicare savings===
Spending reductions included a reduction in Medicare reimbursements to insurers and drug companies for private [[Medicare Advantage]] policies that the [[Government Accountability Office]] and [[Medicare Payment Advisory Commission]] found to be excessively costly relative to government Medicare;<ref name=CMSMedicarePPACA/><ref>{{cite web |title=Higher Spending Relative to Medicare Fee-for-Service May Not Ensure Lower Out-of-Pocket Costs for Beneficiaries |url=http://www.gao.gov/products/GAO-08-522T |publisher=Government Accountability Office |date=February 8, 2008 |accessdate=October 7, 2013}}</ref> and reductions in Medicare reimbursements 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 subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.<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 the ACA's companion legislation, the [[Health Care and Education Reconciliation Act of 2010]], an additional Medicare tax of 3.8% was applied to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)<ref>{{Cite web|url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr4872enr/pdf/BILLS-111hr4872enr.pdf|title=HCERA section 1402}}</ref>

====Excise taxes====
[[Excise taxes (U.S.)|Excise taxes]] for the [[Affordable Care Act]] raised $16.3 billion in [[fiscal year]] 2015 (17% of all excise taxes collected by the Federal Government). $11.3 billion was raised by an excise tax placed directly on health insurers based on their market share. The ACA also includes an excise tax of 40% ("[[Cadillac tax]]") on total employer premium spending in excess of specified dollar amounts ($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, originally scheduled to take effect in 2018, but delayed until 2020 by the [[Consolidated Appropriations Act, 2016]]. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well.<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' health insurance{{anchor|Dependent's Health Insurance}}===

Dependents were permitted to remain on their parents' insurance plan until their 26th birthday, including dependents who no longer live 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 |deadurl=yes |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 |df=mdy-all }}</ref>

===Employer mandate===
Businesses that employ 50 or more people but do not offer health insurance to their full-time employees pay a tax penalty if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the [[#Employer mandate and part-time working hours|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/> Approximately 44% of the population was covered directly or indirectly through an employer.<ref name=kffunin/><ref name=kffpoll/>

===Delivery system reforms===
The act includes a host of [[Healthcare industry#Delivery of services|delivery system]] reforms intended to constrain healthcare costs and improve quality. These include Medicare payment changes to discourage [[hospital-acquired condition]]s and [[hospital readmission|readmissions]], [[bundled payment]] initiatives, the [[Center for Medicare and Medicaid Innovation]], the [[Independent Payment Advisory Board]], and the creation of [[Accountable care organization]]s.

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

The [https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html Hospital Readmissions Reduction Program] (HRPP) was established as an addition to the [[Social Security Act]], in an effort to reduce [[Hospital Readmission|hospital readmissions]]. This program penalizes hospitals with higher than expected readmission rates by decreasing their Medicare reimbursement rate.

====Bundled Payments====
The [[Medicare (United States)|Medicare]] payment system switched from [[fee-for-service]] to [[bundled payment]]s.<ref>{{cite web |url=http://www.medscape.com/viewarticle/748502 |title=Access |publisher=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 [[hip replacement]]) rather than individual payments to individual service providers. In addition, the [[Medicare Part D coverage gap]] (commonly called the "donut hole") was to shrink incrementally, closing completely by January 1, 2020.<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 |dead-url=yes |df=mdy-all }}</ref>

====Accountable Care Organizations====
The Act allowed the creation of Accountable Care Organizations&nbsp;(ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated, high quality&nbsp;care&nbsp;to Medicare patients. ACOs were allowed to continue using a fee for service billing approach. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigation of chronic disease.&nbsp;If they fail to do so, they are subject 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 organization|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 donut hole===
Medicare Part D participants received a 50% discount on brand name drugs purchased after exhausting their [[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> The [[United States Department of Health and Human Services]] began mailing rebate checks in 2010.<ref name = "fostersaug">Claffey, Jason (August 14, 2010).  [http://www.fosters.com/apps/pbcs.dll/article?AID=/20100812/GJNEWS_01/708129744/0/FOSNEWS "Medicare 'Doughnut Hole' Checks in the Mail"]. ''[[Foster's Daily Democrat]]''. Retrieved December 26, 2012.</ref> By the year 2020, the donut hole will be completely phased out.<ref name="medicare.gov">{{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 |deadurl=yes |archiveurl=https://web.archive.org/web/20130523191556/http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf |archivedate=May 23, 2013 |df=mdy-all }}</ref>

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

In May 2011, Vermont enacted [[Green Mountain Care]], a state-based [[Single-payer health care|single-payer system]] for which they intended to pursue a waiver to implement.<ref name=VermontGMC1/><ref name=VermontGMC2/><ref name=VermontGMC3/> In December 2014, Vermont decided not to continue due to high expected costs.<ref>{{cite news |url=https://www.bostonglobe.com/business/2015/01/25/costs-derail-vermont-single-payer-health-plan/VTAEZFGpWvTen0QFahW0pO/story.html |title=Costs derail Vermont's single-payer health plan |newspaper=The Boston Globe}}</ref>

A number of states have implemented, or are planning to implement, work-requirement waivers for Medicaid, affecting ACE expanded Medicaid, as well.<ref>{{Cite web|url=https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/|title=Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State|last=Aug 09|first=Published:|last2=2019|date=2019-08-09|website=The Henry J. Kaiser Family Foundation|language=en-us|access-date=2019-08-20}}</ref>

===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 name="NewYorkTimesArticle2">{{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=[[The New York Times]]|accessdate=March 29, 2010}}</ref><ref name="multiple2" /><ref name="Carney2">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>
* 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>

===Menu calorie listings===
[[Nutrition labeling requirements of the Affordable Care Act]] were signed into federal law in 2010, but implementation was delayed by the FDA several times until they went into 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 signing the Patient Protection and Affordable Care Act on March 23, 2010]]

===Background===
{{Main|Health care reform in the United States|Health care reform debate in the United States}}
An [[individual mandate]] coupled with subsidies for private insurance as a means for [[universal health care|universal healthcare]] was considered the best way to win the support of the Senate because it had been included in prior bipartisan reform proposals. The concept goes back to at least 1989, when the [[Conservatism in the United States|conservative]] [[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 Party (United States)|Republican]] senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of [[free rider problem]]s. 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]] [[Clinton health care plan of 1993|proposed a healthcare reform bill]] in 1993 that included a mandate for employers to provide health insurance to all employees through a regulated marketplace of [[health maintenance organization]]s. Republican Senators proposed an alternative that would have required individuals, but not employers, to buy insurance.<ref name="nyt-mandate"/> Ultimately the Clinton plan failed amid an unprecedented barrage of negative advertising funded by politically conservative groups and the health insurance industry and due to concerns that it was overly complex.<ref name=newsweek-clinton/> Clinton negotiated a compromise with the [[105th United States Congress|105th Congress]] to instead enact the [[State Children's Health Insurance Program|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 |agency=[[Associated Press]] for [[NewsMax]] |first=Beth |last=Fouhy |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}}</ref>

[[File:U.S. Senator John Chafee.jpg|thumb|John Chafee]]
The 1993 Republican alternative, introduced by Senator [[John Chafee]] as the [[Health Equity and Access Reform Today Act]], contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'.<ref name=kaiserhealthnews1993/> Advocates for the 1993 bill included prominent Republicans such as Senators [[Orrin Hatch]], [[Chuck Grassley]], [[Bob Bennett (politician)|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> Of 1993's 43 Republican Senators, 20 supported the HEART Act.<ref name=forbes1/><ref name=politifact1993/> Another Republican proposal, introduced in 1994 by Senator [[Don Nickles]] (R-OK), the Consumer Choice Health Security Act, contained an individual mandate with a penalty provision;<ref>{{cite web |url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |newspaper=Colorado Statesman |accessdate=July 29, 2012}}</ref> however, Nickles subsequently removed the mandate from the bill, stating he had decided "that 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 with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for [[George H. W. Bush]], remarked, "I don't remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax."<ref name="forbes1"/>

[[File:P112912PS-0444 - President Barack Obama and Mitt Romney in the Oval Office - crop.jpg|thumb|Mitt Romney's [[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, [[Massachusetts health care reform|an insurance expansion bill]] was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an [[health insurance marketplace|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 [[Massachusetts health care reform#Commonwealth Health Insurance Connector Authority|'Health Connector' exchange]] and individual mandate in Massachusetts was at first lauded by Republicans. During [[Mitt Romney presidential campaign, 2008|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, a year after the Massachusetts reform, Republican Senator [[Bob Bennett (politician)|Bob Bennett]] and Democratic Senator [[Ron Wyden]] introduced the [[Healthy Americans Act]], which featured an individual mandate and state-based, [[health insurance marketplace|regulated insurance markets]] called "State Health Help Agencies".<ref name=new-yorker-klein/><ref name=new-yorker-lizza/> The bill initially attracted bipartisan support, but died in committee. Many of the [[Healthy Americans Act#Sponsors and co-sponsors|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 that the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill<ref name="kaiserhealthnews1993"/> and that it was deliberately patterned after Romney's state healthcare plan.<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===
{{See also|Health care reforms proposed during the Obama administration}}
Healthcare reform was a major topic during the [[2008 Democratic presidential primaries]]. As the race narrowed, attention focused on the plans presented by the two leading candidates, [[Hillary Clinton]] and the eventual nominee, [[Barack Obama]]. Each candidate proposed a plan to cover the approximately 45&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 [[subsidy]] but rejected the use of an individual 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 [[2008 United States presidential election|general election]], Obama said that fixing healthcare would be one of his top four priorities as president.<ref name="Sep2008FirstPresidentialDebate" /> Obama and his opponent, Sen. [[John McCain]], proposed health insurance reforms though they differed greatly. Senator John McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2 million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018.<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 [[Barack Obama speech to joint session of Congress, September 2009|addressing Congress regarding healthcare reform]], September 9, 2009]]
After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.<ref name="Feb2009JointSessionAddress"/><ref name="reuterstimeline"/> By July, a series of bills were approved by committees within the [[United States House of Representatives|House of Representatives]].<ref name="EdLaborJul2009"/> On the Senate side, from June to September, the [[United States Senate Committee on Finance|Senate Finance Committee]] held a series of 31 meetings to develop a healthcare reform bill. This group—in particular, Democrats [[Max Baucus]], [[Jeff Bingaman]] and [[Kent Conrad]], along with Republicans [[Mike Enzi]], [[Chuck Grassley]] and [[Olympia Snowe]]—met for more than 60 hours, and the principles that they discussed, in conjunction with the other committees, became the foundation of the Senate healthcare reform bill.<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=01/06/2009&date-to=01/02/2011 |dead-url=yes |archive-date=2012-08-02 |title=Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN |publisher=C-SPAN }}</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 |deadurl=yes |archiveurl=https://web.archive.org/web/20130111185729/http://www.finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |archivedate=January 11, 2013 |df=}}</ref>

Congressional Democrats and health policy experts like [[MIT]] economics professor [[Jonathan Gruber (economist)|Jonathan Gruber]]<ref name="GruberBio2"/> and [[David Cutler]] argued that [[guaranteed issue]] would require both [[community rating]] and an individual mandate to ensure that [[adverse selection]] and/or [[Free rider problem|"free riding"]] would not result in an [[Death spiral (insurance)|insurance "death spiral"]].<ref name="HowTheyDidIt"/> This approach was taken because the president and congressional leaders had concluded that more progressive plans, such as the [[Single-payer health care|(single-payer)]] [[United States National Health Care Act|Medicare for All act]], could not obtain [[Supermajority#United States|filibuster-proof support]] in the Senate. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate majority leaders [[Howard Baker]], [[Bob Dole]], [[Tom Daschle]] and [[George J. Mitchell]]—the bill's drafters hoped to garner the votes necessary for passage.<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 adoption of an individual mandate, Republicans came to oppose the mandate and threatened to [[Filibuster in the United States Senate|filibuster]] any bills that contained it.<ref name="forbes1" /> Senate minority leader [[Mitch McConnell]], who led the Republican congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to prevent defections.<ref name="ChaitLegislativeStrategy"/>

Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". Journalist [[Ezra Klein]] wrote in ''[[The New Yorker]]'' that "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."<ref name="new-yorker-klein"/> Reporter Michael Cooper of ''[[The New York Times]]'' wrote that: "the provision ... requiring all Americans to buy health insurance has its roots in conservative thinking."<ref name="nyt-mandate"/><ref name="politifact1993"/>
[[File:9.12 tea party in DC.jpg|thumb|Tea Party protesters at the [[Taxpayer March on Washington]], September 12, 2009]]
The reform negotiations also attracted attention from [[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 certain lobby groups and the advocates of the law to win the support of groups that had opposed past reforms, as in 1993.<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> The [[Sunlight Foundation]] documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both parties.<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 |dead-url=yes |df=mdy-all }}</ref>

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

When Congress returned from recess, in September 2009 [[Barack Obama speech to joint session of Congress, September 2009|President Obama delivered a speech to a joint session of Congress]] supporting the ongoing Congressional 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 used 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 [[United States Senate Committee on Health, Education, Labor, and Pensions|Health]] and [[United States Senate Committee on Finance|Finance]] committees. With the Republican Senate minority vowing to [[Filibuster in the United States Senate|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 United States Congress#Party summary|111th Congress]], Democrats had only 58 votes; [[United States Senate election in Minnesota, 2008|the Senate seat in Minnesota]] ultimately won by [[Al Franken]] was still undergoing a recount, while [[Arlen Specter]] was still a Republican (he became a Democrat in April, 2009).

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

After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Majority leader [[Harry Reid]] focused on satisfying centrists. The holdouts came down to [[Joe Lieberman]] of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat [[Ben Nelson]]. Lieberman's demand that the bill not include a [[Public health insurance option|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 [[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 debate|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 repealed in the subsequent reconciliation amendment bill.

On December 23, the Senate voted 60–39 to end debate on the bill: a [[Cloture#United States|cloture vote]] to end the [[Filibuster in the United States Senate|filibuster]].<ref name="USS RC 2009-395">{{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=[[United States Senate|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|AMA]] 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, [[Massachusetts]] Republican [[Scott Brown (politician)|Scott Brown]] was elected to the Senate in [[United States Senate special election in Massachusetts, 2010|a special election to replace 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 had become significant because of its effects on the legislative process. The first was psychological: the symbolic importance of losing Kennedy's [[Massachusetts#Politics|traditionally Democratic Massachusetts seat]] made many Congressional Democrats concerned about the political cost of passing a 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 [[Cloture#United States|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; [[Speaker of the United States House of Representatives|House Speaker]] [[Nancy Pelosi]] pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care".<ref name="nytimesjourney"/><ref name="PoliticoPelosi"/>

Obama remained insistent on comprehensive reform. The news that [[Anthem (company)|Anthem]] in [[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 that the House would pass the Senate's bill, to avoid another Senate vote.

House Democrats had expected to be able to negotiate changes [[United States congressional conference committee|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 of 2010|Health Care and Education Reconciliation Act]], which could be passed by the [[Reconciliation (United States Congress)|reconciliation process]].<ref name="nytimesjourney" /><ref name="Reconciliationprimer"/><ref name="538Paths218"/>

Per the [[Congressional Budget and Impoundment Control Act of 1974|Congressional Budget Act of 1974]], reconciliation cannot be subject to a [[Filibuster in the United States Senate|filibuster]]. But reconciliation is [[Reconciliation (United States Congress)#Byrd Rule|limited to budget changes]], which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations.<ref>{{cite news |first=Nate |last=Silver |url=http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |title=1. Reconciliation! 2. ??? 3. Profit! |work=[[FiveThirtyEight]] |date=January 21, 2010}}</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 [[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 ACA 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> Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act over sixty times; no such attempt by Republicans has been successful.<ref>{{cite web |title=On Groundhog Day, Republicans vote to repeal Obamacare |publisher=[[MSNBC]] |date=February 2, 2016 |author=Benen, Steve |url=http://www.msnbc.com/rachel-maddow-show/groundhog-day-republicans-vote-repeal-obamacare}}</ref> The amendment bill, The Health Care and Education Reconciliation Act, cleared the House on March 21; the Senate passed it by reconciliation on March 25, and Obama signed it on March 30.

==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 ACA/Obamacare was responsible for 23 million persons covered via exchanges and Medicaid expansion.<ref name=CBO_Subsidy2016/>]]
[[File:ACA Panel Chart v1.png|thumb|upright=2.05|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===
{{See also|Health insurance coverage in the United States}}
The law has caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% from January to June 2016.<ref name=CDC1>{{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 name="FiveThirtyEight - uninsured rate">{{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 [[Congressional Budget Office]] reported in March 2016 that there were approximately 12 million people covered by the exchanges (10 million of whom received subsidies to help pay for insurance) and 11 million made eligible for Medicaid by the law, a subtotal of 23 million people. An additional 1 million were covered by the ACA's "Basic Health Program," for a total of 24 million.<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 also estimated that the ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4 million for reductions in "employment-based coverage" and "non-group and other coverage."<ref name=CBO_Subsidy2016/>  

(In all discussion of uninsured rates, and changes in uninsured rates due to the ACA, in many states, people 55 or older with either Medicaid, and/or expanded Medicaid, are subject to [[Medicaid estate recovery]]<ref name=":7" /><ref name=":6" /><ref name=":5" /> of all medical expenses paid for them while they were receiving Medicaid or expanded Medicaid.  Thus,  some people in those programs we might think of as actually not having insurance, in the sense that we usually think of insurance, but rather as having a loan for medical expenses until death.  However, the U.S. Census Bureau counts all people with Medicaid and expanded Medicaid as insured,<ref>{{Cite web|url=https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf|title=Health Insurance Coverage in the United States: 2017|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> which will be reflected in the insured numbers appearing here, and which we thus may wish to think of as not truly representative of the number we are desiring to measure.)

The [[United States Department of Health and Human Services|U.S. Department of Health and Human Services]] (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016, a 2.4 million increase over September 2015;<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=22 April 2017 |author=Garrett, Bowen |pages=2}}</ref> In 2016, the 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'' expand it 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 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.<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>

By 2017, nearly 70% of those on the exchanges could purchase insurance for less than $75 per month after subsidies, which rose to offset significant pre-subsidy price increases in the exchange markets.<ref name=NPR1>{{Cite web |url=https://www.npr.org/sections/health-shots/2016/10/24/499190020/rates-rise-again-for-obamacare-health-plans-but-so-do-subsidies |title=Rates Up 22 Percent For Obamacare Plans, But Subsidies Rise, Too |accessdate=November 19, 2016}}</ref> Healthcare premium cost increases in the employer market continued to lessen. 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>{{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> with only a 3% increase from 2015 to 2016.<ref name=Kaiser16>{{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% |website=Kaiser Family Foundation |accessdate=November 23, 2016}}</ref>

The ACA also helps reduce income inequality measured after taxes, due to higher taxes on the top 5% of income earners and both subsidies and Medicaid expansion for lower-income persons.<ref name=Obama_Inequality>{{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 |accessdate=December 6, 2016 |deadurl=yes |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 |df=mdy-all }}</ref> The CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. For scale, the subsidy for the employer market, in the form of exempting from taxation those health insurance premiums paid on behalf of employees by employers, was approximately $1,700 per person in 2016, or $266 billion total in the employer market. The employer market subsidy was not changed by the law.<ref name=CBO_Subsidy2016/>

===Taxes===
[[File:Excise taxes.jpg|Frameless|right|450px|Excise taxes percentage 2015]]
[[Excise tax in the United States|Excise taxes]] for the [[Affordable Care Act]] raised $16.3 billion in [[fiscal year]] 2015. $11.3 billion was an excise tax placed directly on health insurers based on their market share. The ACA was going to impose a 40% "[[Cadillac tax]]" on expensive employer sponsored health insurance but that was postponed until 2018.<ref name="fool.com">{{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 -|first=Dan|last=Caplinger|date=January 7, 2018|website=The Motley Fool}}</ref> Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.32% on medical devices and a 10% excise tax on indoor tanning services were applied as well. The [[Individual mandate]] was $695 per individual or $2,085 per family minimum who wasn't insured and was as high as 2.5% of household income (whichever was higher). The individual mandate was repealed by Republicans ending at the end of 2018.<ref name="fool.com"/> 0.9 percent payroll tax and a 3.8 percent tax on net investment income for individuals with incomes exceeding $200,000 and couples with incomes exceeding $250,000.<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><ref>{{Cite web|url=https://money.cnn.com/2018/03/03/news/economy/obamacare-tax-penalty/index.html|title=The Obamacare tax penalty isn't dead yet|first=Emily Bazar, Kaiser Health|last=News|date=March 3, 2018|website=CNNMoney}}</ref>

===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" />

===Medicaid expansion===
[[File:ACA Medicaid expansion by state.svg|thumb|upright=1.35|Medicaid expansion by state, as of November 7, 2018<ref name=KaiserMedicaid/>
{{legend|#232|Adopted the Medicaid expansion}}
{{legend|#898|Medicaid expansion under discussion}}
{{legend|#C8C8C8|Not adopting Medicaid expansion}}]]

As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.<ref name=KFF_States/> Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did ''not'' expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64.<ref name=Urban_Q12016/> Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they didn't expand Medicaid under the ACA, several states rejected expanded Medicaid coverage. Over half of the national uninsured population lived in those states.<ref name=NYT52413/> In a report to Congress, the [[Centers for Medicare and Medicaid Services]] (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults.<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 name=KFF_Medicaid15>{{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>

States that rejected the Medicaid expansion could maintain their Medicaid eligibility thresholds, which in many states 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 in Kansas.<ref name=NYT52413/>

Studies of the impact of state decisions to reject the Medicaid expansion calculated that up to 6.4 million people could fall into this status.<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> The federal government initially paid for 100% of the expansion (through 2016). The subsidy tapered to 90% by 2020 and continued to shrink thereafter.<ref name="CNNMedicaid"/> Several states argued that they could not afford their 10% contribution.<ref name="CNNMedicaid" /><ref name="Medicaiddeal"/> Studies suggested that rejecting the expansion would cost more than expanding Medicaid due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,<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 accepted the Medicaid expansion, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills than before the expansion. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period.<ref name=":9">{{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. The new Arkansas and Kentucky governors have 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}}</ref>

A 2016 [[United States Department of Health and Human Services|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>

===Healthcare insurance costs===
{{See also|Health care prices in the United States}}
[[File:US healthcare cost panel v1.png|thumb|upright=2.05|right|U.S. healthcare cost information, including rate of change, per-capita, and percent of GDP. (Data source: [[Centers for Medicare and Medicaid Services]]<ref>{{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>)]]

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

Healthcare premium cost increases in the employer market continued to moderate after the implementation of the law. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015,<ref name=Kaiser15/> with only a 3% increase from 2015 to 2016.<ref name=Kaiser16/> From 2008 to 2010 (before passage of the ACA) health insurance premiums rose by an average of 10% per year.<ref name=CW_1>{{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 [[Financial crisis of 2007–08|financial crisis]] and accompanying recession could not account for the entirety of the slowdown and that structural changes likely share 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> 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 [[Medicare (United States)#Costs and funding challenges|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 of the ACA published in ''[[JAMA (journal)|JAMA]]'', Barack Obama himself wrote that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.<ref>Obama, B, JD. United States Health Care Reform – Progress to Date and Next Steps. JAMA. Published online July 11, 2016. {{DOI|10.1001/jama.2016.9797}}</ref>

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

For those who obtain their insurance through their employer ("group market"), a 2016 survey found that:
* Deductibles grew by 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 drops 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 the ACA exchanges, a survey of 2015 data found that:
* 49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
* Many marketplace 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 the ACA exchanges felt "well protected" by their insurance, in the group market 63% felt that way.<ref>{{Cite web |url=http://kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/ |title=Survey of Non-Group Health Insurance Enrollees, Wave 3 |date=May 20, 2016 |website=kff.org |publisher=Kaiser Family Foundation |accessdate=September 14, 2016}}</ref>

===Health outcomes===
[[File:U.S. Mortality - Premature Death Rates by County.png|thumb|right|upright=2.05|The map illustrates the frequency of premature deaths (those under age 75) adjusted for the age of persons in the county.<ref name="FRED_Map1"/>]]

Insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.<ref name="WaPo_Covg">{{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> [[City University of New York|City University]] public health professors David Himmelstein and Steffie Woolhandler wrote in January 2017 that a rollback of the ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.<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=2017-01-23}}</ref>

The Federal Reserve publishes data on premature death rates by county, defined as those dying below age 74.<ref name="FRED_Map1">{{Cite web|url=https://fredblog.stlouisfed.org/2017/11/theres-death-and-then-theres-death/|title=There's death and then there's death &#124; FRED Blog}}</ref> According to the Kaiser Foundation, expanding Medicaid in the remaining 19 states would cover up to 4.5 million persons.<ref name="Kaiser_Gap">{{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> Since expanding Medicaid expands coverage<ref name="Kaiser_Gap"/> and expanding coverage reduces mortality,<ref name="WaPo_Covg"/> therefore expanding Medicaid reduces mortality by [[syllogism]]. Texas, Oklahoma, Mississippi, Alabama, Georgia, Tennessee, Missouri and South Carolina, indicated on the map at right as having many counties with high premature mortality rates,<ref name="FRED_Map1"/> could therefore reduce mortality by expanding Medicaid, other things equal.

Two 2018 ''[[JAMA (journal)|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=2018-01-01|title=Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure|url=https://jamanetwork.com/journals/jamacardiology/fullarticle/2663213|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=2018-12-25|title=Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia|url=https://jamanetwork.com/journals/jama/fullarticle/2719307|journal=JAMA|language=en|volume=320|issue=24|pages=2542–2552|doi=10.1001/jama.2018.19232|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=2018-12-27|website=Reason.com|language=en-US|access-date=2019-06-06}}</ref> A 2019 ''JAMA'' study found that the ACA 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=2019-04-05|title=US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act|url=https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730788|journal=JAMA Network Open|language=en|volume=2|issue=4|pages=e192662|doi=10.1001/jamanetworkopen.2019.2662}}</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. The ACA raised taxes mainly on the top 1% to fund approximately $600 in benefits on average for the bottom 40% of families.]]
In March 2018, the CBO reported that the ACA had reduced income inequality in 2014, saying that 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====
{{See also|United States public debt|Provisions of the Patient Protection and Affordable Care Act}}
The CBO reported in several studies that the ACA would reduce the deficit, and that repealing it would increase the deficit.<ref name="CBO50252"/><ref name="CBO22077"/><ref>{{cite web |url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/121xx/doc12119/03-30-healthcarelegislation.pdf |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |first=Douglas W. |last=Elmendorf |date=March 30, 2011 |publisher=[[Congressional Budget Office]] |accessdate=July 15, 2012}}</ref><ref>{{cite web |url=http://cbo.gov/sites/default/files/cbofiles/attachments/06-21-Long-Term_Budget_Outlook.pdf |title=CBO's 2011 Long-Term Budget Outlook |first=Douglas W. |last=Elmendorf |date=June 21, 2011 |page=44 |publisher=[[Congressional Budget Office]] |quote=Through those changes and numerous others, the 2010 legislation significantly decreased Medicare outlays relative to what they would have been under prior law.}}</ref> 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 [[Government spending|total outlays]] offset by $813 billion in [[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 that the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs"<ref name="CBO-Reid-Dec2009"/>—ultimately extending the solvency of the [[Medicare (United States)#The solvency of the Medicare HI trust fund|Medicare trust fund]] by 8 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 [[#Legal challenges|Supreme Court's ruling]] that enabled states to [[#State rejections of Medicaid expansion|opt out of the Medicaid expansion]], thereby forgoing the related federal funding. The [[Congressional Budget Office|CBO]] and [[United States Congress Joint Committee on Taxation|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 ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic [[dynamic scoring|feedback]] effects. The CBO also forecasted that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 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 |publisher=[[PolitiFact.com]] |accessdate=April 7, 2010}}</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 |deadurl=yes |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 |df=mdy-all }}</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 |dead-url=yes |df=mdy-all }}</ref> However, the so-called "doc fix" is a separate issue that would have existed whether or not ACA became law – omitting its cost from ACA was no different from omitting the cost of other tax [[Bush tax cuts|cuts]].<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}}</ref>

[[Uwe Reinhardt]], a Princeton [[health economist]], wrote. "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the [[Medicare Prescription Drug, Improvement, and Modernization Act|Medicare Modernization Act of 2003]]."<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]], CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator [[John McCain]]'s 2008 presidential campaign, alleged that the bill would increase the deficit by $562&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 that for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from [[Preventive medicine|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 record]]s<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 ... 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 M. Walker (U.S. Comptroller General)|David Walker]], former [[Comptroller General of the United States|U.S. Comptroller General]] then working for [[The Peter G. Peterson Foundation]], stated that the CBO estimates are not likely to be accurate, because they were based on the assumption that the law would not change.<ref name="deficit_david_walker_cbo_innacurate"/> 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 payment reductions addressed by the annual "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}}</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>

===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 the ACA would:
* Decrease aggregate demand (GDP) in the short-term, as low-income persons who tend to spend a large fraction of their additional resources would have fewer resources (e.g., ACA subsidies would be eliminated). This effect would be offset in the long-run by the labor supply factors below.
* Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021–2025 period. CBO cited the ACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing the ACA would remove those disincentives, encouraging workers to supply more hours of labor.
* Increase 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 additional investment, raising the capital stock and output in the long-run.<ref name="CBO50252"/>

In 2015 the [[Center for Economic and Policy Research]] found no evidence that companies were reducing worker hours to avoid ACA requirements<ref>{{Cite web |url=https://www.randstadusa.com/workforce360/workforce-insights/the-affordable-care-act-and-employers/91/ |title=The Affordable Care Act and Employers |accessdate=August 11, 2016}}</ref> for employees working over 30 hours per week.<ref>{{cite web |title=Is the Affordable Care Act a Hidden Jobs Killer? |url=http://www.cepr.net/blogs/cepr-blog/is-the-affordable-care-act-a-hidden-jobs-killer |website=Center for Economic and Policy Research |publisher=CEPR |accessdate=August 26, 2015}}</ref>

The CBO estimated that the ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Cohn, citing CBO's projections, claimed that ACA's primary employment effect was to alleviate [[job lock]]: "People who are only working because they desperately need employer-sponsored health insurance will no longer do so."<ref name="CBOjobs"/> He concluded that the "reform's only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire", because they have health insurance outside of their jobs.<ref name="ACAEconomyCohn"/>

===Employer mandate and part-time work===
{{Details|topic=health insurance mandates|Health insurance mandate}}
The employer mandate requires employers meeting certain criteria to provide health insurance to their workers. The mandate applies to employers with more than 50 employees that do not offer health insurance to their full-time workers.<ref name=GPO/> Critics claimed that the mandate created a [[perverse incentive]] for business to keep their full-time headcount below 50 and to hire part-time workers instead.<ref name=ChaitNotWreck/><ref name=KliffPartTime/> Between March 2010 and 2014 the number of part-time jobs declined by 230,000, while the number of full-time jobs increased by 2 million.<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 ACA had increased part-time employment.<ref>{{cite journal |last1=Moriya |first1=A. S. |last2=Selden |first2=T. M. |last3=Simon |first3=K. I. |title=Little Change Seen In Part-Time Employment As A Result Of The Affordable Care Act |journal=Health Affairs |date=January 5, 2016 |volume=35 |issue=1 |pages=119–123 |doi=10.1377/hlthaff.2015.0949}}</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 yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).<ref name=KliffPartTime/> <!--AS OF WHEN?? --> Trends in working hours<ref name="NPRPartTime"/> and the effects of the [[Great Recession]] correlate with part-time working hour patterns.<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 |deadurl=yes |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> The impact of this provision may have been offset by other factors, including that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and the lower training and administration costs of a smaller full-time workforce over a larger part-time work force.<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 offered insurance.<ref name="CohnDelay"/> Workers without employer insurance could purchase insurance on the exchanges.<ref>{{cite web |title=Am I eligible for coverage in the Marketplace? |url=https://www.healthcare.gov/am-i-eligible-for-coverage-in-the-marketplace |publisher=HealthCare.Gov, managed by the [[Centers for Medicare and Medicaid Services]]}}</ref>

Most policy analysts (on 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 [[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 effects of the provision generated vocal opposition from business interests and some unions 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>

A 2013/4 survey by the [[National Association for Business Economics]] found that about 75 percent of those surveyed said ACA hadn't influenced their planning or expectations for 2014, and 85 percent said the law wouldn't prompt a change in their hiring practices. Some 21 percent of 64 businesses surveyed said that the act would have a harmful effect and 5 percent said it would be beneficial.<ref>{{cite web |url=http://www.businessweek.com/news/2014-01-27/economists-see-little-effect-on-hiring-from-u-dot-s-dot-health-care-law |title=Economists See Little Effect on Hiring From U.S. Health-Care Law |last1=Torres |first1=Carlos |date=January 27, 2014 |website=www.businessweek.com |publisher=Bloomberg L.P. |accessdate=January 27, 2014}}</ref>

===Hospitals===
From the start of 2010 to November 2014, 43 hospitals in [[Rural area#United States|rural areas]] closed. Critics claimed that the new law caused these hospitals to close. Many of these rural hospitals were built using funds from the 1946 [[Hill–Burton Act]], to increase access to [[Rural health|medical care in rural areas]]. Some of these hospitals reopened as other medical facilities, but only a small number operated [[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 emergency room doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed that they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured patients.<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>

Insurers claimed that because they have access to and collect patient data that allow evaluations of interventions, they are essential to ACO success. Large insurers formed their own ACOs. Many hospitals merged and purchased physician practices. The increased market share gave them more leverage in negotiations with insurers over costs and reduced patient care options.<ref name=":15" /><br />

== Problems ==

=== Subsidy Cliff at 400% FPL ===
The subsidies for an ACA plan purchased on an exchange stop at 400% of the Federal Poverty Level (FPL).  This results in a sharp "discontinuity of treatment" at 400% FPL, which is sometimes called the "subsidy cliff".<ref>{{Cite web|url=https://www.ehealthinsurance.com/resources/individual-and-family/what-is-the-subsidy-cliff|title=Are You On the Edge of the ACA Subsidy Cliff? - eHealth Insurance|date=2019-07-31|website=eHealth Insurance Resource Center|language=en-US|access-date=2019-08-10}}</ref>People above the subsidy cliff can experience a sharp rise in premiums, making the premiums unaffordable.<ref name=":31">{{Cite web|url=https://money.cnn.com/2016/11/04/news/economy/obamacare-affordable/index.html|title=Is Obamacare actually affordable?|last=Luhby|first=Tami|date=2016-11-04|website=CNNMoney|access-date=2019-08-22}}</ref><ref name=":32">{{Cite web|url=https://khn.org/news/health-insurance-costs-crushing-many-people-who-dont-get-federal-subsidies/|title=Health Insurance Costs Crushing Many People Who Don’t Get Federal Subsidies|last=Findlay|first=Steven|date=2018-12-14|website=Kaiser Health News|language=en-US|access-date=2019-08-22}}</ref>. 

After-subsidy premiums for the second lowest cost silver plan (SCLSP) just below the cliff are 9.86% of Modified Adjusted Gross Income (MAGI) in 2019<ref name=":8" />.  However, upon crossing the cliff, the cost of the plan may rise sharply.

'''Silver plan numbers example''': For example, in Cook County, IL zip 60617, in 2019, one gets from Healthcare.gov<ref name=":26">{{Cite web|url=https://www.healthcare.gov/see-plans/|title=Health insurance plans & prices|website=HealthCare.gov|language=en|access-date=2019-08-10}}</ref>  a SCLSP rate of $21,266 for a married couple 63 years of age.  If the couple's income is 401% of the FPL<ref>{{Cite web|url=https://aspe.hhs.gov/poverty-guidelines|title=Poverty Guidelines|date=2015-11-23|website=ASPE|language=en|access-date=2019-08-11}}</ref>, just above the cliff, that works out to $84, 731.  If the couple chooses the SCLSP, it will cost them 25.1% of their Modified Adjusted Gross Income. If their MAGI was 399% of the FPL (i.e. not over the cliff) at $84,308, the SCLSP  would only have costed them 9.86% of their MAGI, or $8,312.  The jump in cost at the discontinuity is $12,954.

'''Bronze plan alternative numbers example''': In the case of certain states and certain insurers, for people above 250% of FPL, who don't get cost-sharing reductions (CSRs), plans besides silver may provide better value.  (This is because when payment by the Federal Government of cost-sharing reduction compensation payments to insurers was stopped by the Trump administration, certain states either ordered insurers, or allowed insurers optionally, to assess actuarial costs for the cost-sharing reductions that they had to pay for silver plan enrollees with FPLs below 250% FPL,  to silver-plan-premiums only.<ref name=":29">{{Cite web|url=https://docs.google.com/spreadsheets/d/1W2EQhCXowRDDuqJhy6PUJtIGHjoND9f_K7oALyDAbLg/edit?usp=embed_facebook|title=2018 CSR Load Type By State|website=Google Docs|language=en-US|access-date=2019-08-14}}</ref><ref name=":28">{{Cite web|url=https://www.healthaffairs.org/do/10.1377/hblog20180613.293356/full/|title=Health Affairs Blog: Insurers Can Continue Silver Loading for 2019|last=|first=|date=2019-08-24|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>.)  So, we provide also the Bronze plan numbers here for the same couple. 

The second lowest cost bronze plan for the example couple above was $18,513.  At income levels of 399% of FPL and 401% of FPL, the net cost of the second lowest bronze plan would be $5,559 a year and $18,513 respectively.  The jump in cost at the discontinuity point is $12,954, but the percent of MAGI that these represent are 6.6% and 21.9%, respectively. Thus, the second lowest cost bronze plan, though it has an out-of-pocket maximum about $2000 higher than the second lowest cost silver plan, may be slightly better value, but, above the subsidy cliff, at 21.9% of MAGI, it may still be considered unaffordable.  Note that for the gold plans, all gold plans were more expensive than the second lowest cost silver plan, and so those would have all cost more than 25.1% of MAGI for the over-the-cliff case.

'''Affect of loss of Penalty for Not Carrying Coverage on Affordability''' '''over the subsidy cliff:''' Since the penalty for not carrying coverage was designed to reduce adverse selection from people not picking up coverage unless they were sick or more likely to get sick, the removal of the penalty starting in 2019<ref name=":30">{{Cite web|url=https://www.healthcare.gov/fees/fee-for-not-being-covered/|title=Individual Mandate Penalty You Pay If You Don't Have Health Insurance Coverage|website=HealthCare.gov|language=en|access-date=2019-08-14}}</ref> (in states that did not add their own penalty) may increase adverse selection, that is, the likelihood of the people with insurance being sicker than the average in the population, and this may increase premiums for policies.  Since people over the cliff get no subsidy, they would be the most affected.  (People under the cliff point of 400% FPL have a post-subsidy premium bounded currently at at most 9.86% of FPL, so they are less affected.)

=== Sometimes-Unaffordable Out-of-Pocket Maximums ===
Under the ACA, health plans must have out-of-pocket maximums, but these can be quite high<ref name=":31" /><ref name=":32" /><ref name=":41">{{Cite web|url=https://tcf.org/content/report/key-proposals-to-strengthen-the-aca/|title=Key Proposals to Strengthen the Affordable Care Act|date=2015-11-23|website=The Century Foundation|language=en|access-date=2019-08-25}}</ref>.  For 2019, the maximum legally permitted stop-loss is $7,900 for an individual plan and $15,800 for a family plan<ref name=":44">{{Cite web|url=https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/|title=Out-of-pocket maximum/limit - HealthCare.gov Glossary|website=HealthCare.gov|language=en|access-date=2019-08-13}}</ref><ref name=":33">{{Cite web|url=https://www.healthreformbeyondthebasics.org/cost-sharing-charges-in-marketplace-health-insurance-plans-answers-to-frequently-asked-questions/|title=Key Facts: Cost-Sharing Charges|website=Beyond the Basics|language=en-US|access-date=2019-08-22}}</ref>., though the maximums allowed are somewhat lower for people eligible for cost-sharing reductions on the exchange.<ref>{{Cite web|url=https://www.healthreformbeyondthebasics.org/cost-sharing-charges-in-marketplace-health-insurance-plans-part-2/|title=Key Facts: Cost-Sharing Reductions|website=Beyond the Basics|language=en-US|access-date=2019-08-13}}</ref> (People eligible for cost-sharing reductions are those eligible for a subsidized on-exchange plan who further have MAGIs between 100% and 250% of the Federal Poverty Level.) <br />

Policies may have lower out-of-pocket maximums than the legal maximum, and they tend to be lower for the higher grades of plans, like the Platinum and Gold, but they don't have to be<ref name=":33" />.

'''Example, sliver plan''': reusing from the ''subsidy cliff'' example of Cook County, IL zip 60617, for a  married couple aged 63, with an income around 400% FPL, in 2019, one gets from Healthcare.gov<ref name=":26" />  for the second lowest cost silver plan an individual stop-loss per family member of $7,050 with $14,100 allowed total for the couple.  Since the income is about $84,500, the stop-loss works out to about 17% of MAG Income. So the couple has to allow that they may need to pay the out of pocket max, in addition to the premium, which for them in the ''subsidy cliff'' calculation, was 25.1% of MAG income if they were just a bit over the subsidy cliff.  So we have total medical expenses potentially at 42% of MAGI in that case, and still about 27% of MAG income even if they were under the subsidy cliff.

'''Example, bronze plan''': switching to second lowest cost bronze plan: The stop-loss is $15,800, or 19% of MAG Income.  Above the subsidy cliff, since premiums were 22% of MAGI, total annual medical expenses could be 41% of MAGI.  (1% less than silver.)

=== Family Glitch ===
One requirement to get a subsidized on exchange health insurance plan, is to not have access to affordable employer coverage through any family member's employer, with ''affordable'' defined to be no more than 9.86% MAGI for ''just the employee's coverage'').  This may leave a family with no option for affordable coverage.  That is, the employer coverage for the ''whole family,'' could be, say, 25% of MAGI, making it unaffordable.  This issue is called the ''family glitch''.<ref name=":27" /><ref>{{Cite web|url=https://www.healthaffairs.org/do/10.1377/hpb20141110.62257/full/|title=The Family Glitch {{!}} Health Affairs|website=www.healthaffairs.org|language=en|doi=10.1377/hpb20141110.62257/full/|access-date=2019-08-22}}</ref><ref name=":41" />

=== Estate Recovery under 138% FPL ===
For Medicaid (including the ACA's expanded Medicaid), in a number of states, all medical expenses paid out, for people 55 or over while they received the Medicaid or Expanded Medicaid, are subject to [[Medicaid estate recovery]].<ref name=":5" /> <ref name=":6" /> <ref name=":7" />   (States are required by Federal law to recover all long-term-care-related expenses<ref name=":36">{{Cite web|url=https://aspe.hhs.gov/basic-report/medicaid-estate-recovery|title=Medicaid Estate Recovery|date=2015-12-09|website=ASPE|language=en|access-date=2019-08-22}}</ref> from estates, but also have the option of recovering costs of all other Medicaid services for people 55 and older.<ref name=":5" /> <ref name=":6" /> <ref name=":7" /><ref name=":36" />)  In the view of some, in states that do estate recovery beyond long-term-care-related expenses, people 55 and over with Medicaid coverage don't have health insurance, but rather have a loan until they die.<ref>{{Cite web|url=https://www.huffpost.com/entry/medicaid-estate-recovery-program-alec_n_4674277|title=Latest Obamacare Horror Provision Was Championed By ALEC|last=Stein|first=Sam|date=2014-01-27|website=HuffPost|language=en|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.paelderlaw.com/practice-areas/elder-law-asset-protection/medical-assistance-estate-recovery/|title=Medical Assistance Estate Recovery|date=2012-09-27|website=Marshall, Parker & Weber LLC|language=en-US|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.dailykos.com/story/2013/10/21/1249471/-Estate-Recovery-It-s-Worse-Than-You-Thought|title=Estate Recovery - It's Worse Than You Thought.|website=Daily Kos|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.iowa-estates.com/AAPWAConfOutline.pdf|title=Medicaid Estate Recovery (American Association of Public Welfare Attorneys). See p. 4 and other pages for loan terminology|last=|first=|date=2019-08-21|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>)

People eligible for Medicaid are not eligible for any subsidy on a major medical plan on the health insurance exchanges<ref name=":8" />  Since a large proportion of those people have Modified Adjusted Gross Incomes (MAGI) of no more than 138% of the Federal Poverty Level (FPL), many will be forced to rely on the Medicaid they are eligible for, with the estate recovery.

The issue of the negative interaction of the ACA with Medicaid estate recovery was noticed in many places starting from the time of ACA passage.<ref name=":35">{{Cite web|url=https://www.healthaffairs.org/do/10.1377/hblog20140224.037390/full/|title=Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act {{!}} Health Affairs|website=www.healthaffairs.org|language=en|doi=10.1377/hblog20140224.037390/full/|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.seattletimes.com/seattle-news/expanded-medicaidrsquos-fine-print-holds-surprise-lsquopaybackrsquo-from-estate-after-death/|title=Expanded Medicaid’s fine print holds surprise: ‘payback’ from estate after death|last=Ostrom|first=Carol M.|date=2013-12-16|website=The Seattle Times|language=en-US|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.paulcraigroberts.org/2014/02/08/obamacare-final-payment-raiding-assets-low-income-poor-americans/|title=Obamacare: The Final Payment--Raiding the Assets of Low-Income and Poor Americans - PaulCraigRoberts.org|website=www.paulcraigroberts.org|language=en-US|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.huffpost.com/entry/beware-of-the-medicaid-bi_b_10185884|title=Beware of the Medicaid 'Big Con'|last=Waldman|first=Deane|last2=ContributorDirector|date=2016-05-31|website=HuffPost|language=en|access-date=2019-08-21|last3=Center|first3=Texas Health Care Policy}}</ref><ref name=":37">{{Cite web|url=https://www.twincities.com/2016/02/15/mnsure-medicaid-estate-claims-health-obamacare-affordable-care-act/|title=Some shocked by estate claims after joining Medicaid via MNsure|last=Service|first=John Lundy {{!}} Forum News|date=2016-02-16|website=Twin Cities|language=en-US|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.pbs.org/newshour/show/medicaid-bill-doesnt-go-away-die|title=The Medicaid bill that doesn't go away when you die|date=2015-03-24|website=PBS NewsHour|language=en-us|access-date=2019-08-21}}</ref><ref name=":38">{{Cite web|url=https://www.macpac.gov/wp-content/uploads/2015/11/Medicaid%E2%80%99s-New-Adult-Group-and-Estate-Recovery.pdf|title=MACPAC Issue Brief on Medicaid's New Adult Group and Estate Recovery (Nov 2015)|last=|first=|date=2019-08-21|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://www.consumerreports.org/cro/news/2014/01/will-medicaid-take-my-house-when-i-die/index.htm|title=Iowa State Recovery: Will Medicaid take my house? - Consumer Reports|website=www.consumerreports.org|access-date=2019-08-21}}</ref><ref>{{Cite web|url=http://www.startribune.com/minnesota-should-back-off-on-medicaid-estate-recovery/369194331/|title=EDITORIAL {{!}} Minnesota should back off on Medicaid estate recovery|website=Star Tribune|access-date=2019-08-21}}</ref><ref name=":39">{{Cite web|url=https://www.kqed.org/stateofhealth/24668/on-medi-calnow-lose-your-house-later|title=On Medi-Cal Now, Lose Your House Later?|date=2015-03-24|website=KQED|language=en-us|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.ocregister.com/2015/05/19/ask-emily-medi-cal-will-charge-your-heirs-for-your-care-after-you-die/|title=Ask Emily: Medi-Cal will charge your heirs for your care after you die|date=2015-05-19|website=Orange County Register|language=en-US|access-date=2019-08-21}}</ref><ref>{{Cite web|url=https://www.openminds.com/market-intelligence/executive-briefings/medicaid-estate-recovery-look-like-state/|title=What Is Happening With Medicaid Estate Recovery – And Why It Matters|website=OPEN MINDS|language=en-US|access-date=2019-08-21}}</ref><ref name=":40">{{Cite web|url=https://www.washingtonpost.com/national/health-science/little-known-aspect-of-medicaid-now-causing-people-to-avoid-coverage/2014/01/23/deda52e2-794e-11e3-8963-b4b654bcc9b2_story.html|title=Washington Post Article: Little-known aspect of Medicaid now causing people to avoid coverage (Jan, 2014)|last=|first=|date=2019-08-23|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name=":41" />  Criticisms centered on the need to ultimately pay back ACA coverage benefits by the recipient's estate, as well as the unequal treatment of people below 138% of the FPL, who are subject to the recovery, and those just above, who receive very-low-cost, highly subsidized insurance, which is not subject to the recovery.<ref name=":37" /><ref name=":38" /><ref name=":39" /><ref name=":40" />

In apparent reaction to the issue, In February 2014 (two months after the main ACA provisions went into effect), the Obama administration's Center for Medicare and Medicaid Services (CMS) issued a letter requesting states not recover Medicaid expenses other than long-term-care-related expenses for a group that was essentially the Medicaid expansion population, and stating “CMS intends to thoroughly explore options and to use any available authorities" to prevent such recovery.<ref>{{Cite web|url=https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-14-001.pdf|title=HHS Medicaid Letter: Feb, 2014|last=|first=|date=2019-08-22|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name=":35" />

Some states that have expanded Medicaid amended laws and regulations since the passage of the ACA to stop or limit the recovery as it relates to ordinary medical insurance expenses (that is, non-long-term-care-related expenses), or else did not do non-long-term-care-related recovery in the first place.<ref name=":11" /><ref name=":12" /><ref name=":13" /><ref name=":14" />,<ref name=":16" /><ref name=":17" /><ref name=":18" /><ref name=":19" /> <ref name=":21" /><ref name=":22" /><ref>{{Cite web|url=https://www.colorado.gov/pacific/sites/default/files/Medical%20Assistance%20Estate%20Recovery%20Program.pdf|title=Colorado State Medical Assistance Estate Recovery Program (see p. 2 last column)|last=|first=|date=2019-08-15|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://www.pacode.com/secure/data/055/chapter258/chap258toc.html|title=Pennsylvania Code|website=www.pacode.com|access-date=2019-08-19}}</ref><ref>{{Cite web|url=http://www.dhs.pa.gov/cs/groups/webcontent/documents/form/d_009026.pdf|title=PA Medicaid Estate Recovery Document|last=|first=|date=2019-08-18|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> 

Other states that have expanded Medicaid still have regulations indicating they will recover non-long-term-care-related medical expenses. Among these states are NJ, MA,  IA, NV, NH, ND, OH, RI, IN, ID, UT, MD, and the District of Columbia, as well.<ref name=":23" /><ref name=":24" /><ref>{{Cite web|url=https://web.archive.org/web/20140401222908/https://www.usatoday.com/story/news/nation/2014/03/10/medicaid-enrollees-billed-at-death/6262707/|title=Feds worry death rules will limit new Medicaid enrollees|date=2014-04-01|website=web.archive.org|access-date=2019-08-28}}</ref><ref name=":25" /><ref>{{Cite web|url=https://www.state.nj.us/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_You_Should_Know.pdf|title=NJ estate-recovery document|last=|first=|date=2019-08-14|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://dhcf.dc.gov/release/public-notice-medicaid-estate-recovery-fact-sheet|title=Public Notice: Medicaid Estate Recovery Fact Sheet {{!}} dhcf|website=dhcf.dc.gov|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://www.iowalegalaid.org/resource/repayment-of-medicaid-under-iowas-estate-reco#targetText=Iowa%27s%20Estate%20Recovery%20Law%20requires,of%20long%20term%20care%20facilities.&targetText=The%20Estate%20Recovery%20Law%20allows%20certain%20expenses%20to%20be%20paid.|title=Iowa Legal Aid|website=www.iowalegalaid.org|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://dhs.iowa.gov/sites/default/files/Estate%20Recovery_FAQ_FINAL_0.pdf?082220191606|title=Iowa estate recovery document|last=|first=|date=|website=dhs.iowa.gov|archive-url=|archive-date=|dead-url=|access-date=2019-08-22}}</ref><ref>{{Cite web|url=http://dhcfp.nv.gov/Pgms/CPT/MER/|title=MER|website=dhcfp.nv.gov|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://www.dhhs.nh.gov/oos/eru/index.htm|title=Estate Recoveries Unit {{!}} Office of Operations Support {{!}} New Hampshire Department of Health and Human Services|website=www.dhhs.nh.gov|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://www.dhhs.nh.gov/dfa/documents/pamphlet.pdf|title=New Hampshire Estate Recovery Document|last=|first=|date=2019-08-22|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=http://www.nd.gov/dhs/services/medicalserV/medicaid/recovery.html|title=Medicaid Estate Recovery: Medicaid: Medical Services: Services: Department of Human Services: State of North Dakota|website=www.nd.gov|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://medicaid.ohio.gov/Portals/0/Resources/Publications/Forms/ODM07400.pdf|title=Ohio Medicaid Estate Recovery Document|last=|first=|date=2019-08-22|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://rules.sos.ri.gov/regulations/part/210-10-00-4|title=“Collections and Payments: Liens and Recovery of Medicaid Payments” (formerly Medicaid Code of Administrative Rules, Section # 0312) (210-RICR-10-00-4) - Rhode Island Department of State  (see 4.1 and 4.4)|last=|first=|date=|website=rules.sos.ri.gov|language=en|archive-url=|archive-date=|dead-url=|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://medicaid.utah.gov/Documents/pdfs/EstateRecovery.pdf|title=Utah Estate Recovery Document|last=|first=|date=2019-08-24|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://www.in.gov/fssa/dfr/4874.htm|title=FSSA: Medicaid Estate Recovery|website=www.in.gov|access-date=2019-08-24}}</ref><ref>{{Cite web|url=https://www.idahocareline.org/the-idaho-medicaid-estate-recovery-program/|title=The Idaho Medicaid Estate Recovery Program|website=Idaho Care Line (2-1-1)|language=en-US|access-date=2019-08-24}}</ref><ref>{{Cite web|url=https://mmcp.health.maryland.gov/docs/estatefactsheet_1106final.pdf|title=MD Medicaid Estate Recovery Document|last=|first=|date=2019-08-26|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>

An attempt to amend Federal laws to stop non-long-term-care-related Medicaid estate recovery was made in 2018, but the bill has been abandoned.<ref>{{Cite web|url=http://nasmusicsoft.com/BlogMAEstateClawback/FederalAttemptNolan.pdf|title=Estate Recovery Fairness Act Memo|last=|first=|date=2019-08-16|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>

=== Coordination of Medicaids with On-Exchange Plans ===
Medicaid and expanded Medicaid eligibility is determined either by state Medicaid agencies<ref>{{Cite web|url=https://www.policygenius.com/blog/a-state-by-state-guide-to-medicaid/|title=A state-by-state guide to Medicaid: Do I qualify?|date=2018-01-26|website=Policygenius Magazine|language=en|access-date=2019-08-22}}</ref><ref>{{Cite web|url=https://www.macpac.gov/wp-content/uploads/2018/11/Assessment-and-Synthesis-of-Selected-Medicaid-Eligibility-Enrollment-and-Renewal-Processes-and-Systems-in-Six-States.pdf|title=MACPAC report:Assessment and Synthesis of Selected Medicaid Eligibility, Enrollment, and Renewal Processes and Systems in Six States (Oct. 2018)|last=|first=|date=2019-08-21|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>, or by a state or Federal exchange.<ref>{{Cite web|url=https://www.healthcare.gov/glossary/eligibility-assessment/|title=Eligibility Assessment - HealthCare.gov Glossary|website=HealthCare.gov|language=en|access-date=2019-08-22}}</ref>

Enrollment in on-exchange plans, and determination of subsidies, is generally done by a state exchange, or the Federal one, if the state has no exchange<ref>{{Cite web|url=https://www.healthinsurance.org/faqs/what-type-of-health-insurance-exchange-does-my-state-have/|title=What type of health insurance exchange does my state have?|date=2018-10-28|website=healthinsurance.org|language=en|access-date=2019-08-22}}</ref>.

Eligibility for subsidized on-exchange plans is based on annual estimated Modified Adjusted Gross Income (MAGI) and Federal Poverty Level cutpoints that are fixed throughout the calendar year<ref name=":8" />.

Historically, Medicaid agencies have tended to use monthly income,<ref name=":34" /> and further, and may update FPL cutpoints mid year<ref>{{Cite web|url=https://www.hca.wa.gov/assets/free-or-low-cost/22-315.pdf|title=Eligibility Overview Washington Apple Health (Medicaid) Programs|last=|first=|date=2019-08-21|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>.

If state Medicaid agencies and the exchanges are not adept at coordinating both eligibility and continuity of coverage between on-exchange-plans, there can be numerous discontinuity of coverage issues, as well as issues with frequent churning between Medicaid / expanded Medicaid and on-exchange plans.

It is, for example, possible that, for people with incomes that are not constant throughout the year, they can be eligible for neither Medicaid, expanded Medicaid, or a subsidized on-exchange plan in certain months.  They can also be churned between Medicaid plans and subsidized on-exchange plans as often as every month<ref name=":34">{{Cite web|url=https://www.commonwealthfund.org/publications/journal-article/2015/jul/reducing-medicaid-churning-extending-eligibility-twelve|title=Reducing Medicaid Churning: Extending Eligibility for Twelve Months or to End of Calendar Year Are Most Effective {{!}} Commonwealth Fund|website=www.commonwealthfund.org|language=en|access-date=2019-08-21}}</ref><ref>{{Cite journal|last=Swartz|first=Katherine|last2=Short|first2=Pamela Farley|last3=Graefe|first3=Deborah R.|last4=Uberoi|first4=Namrata|date=2015-10-30|title=Evaluating State Options for Reducing Medicaid Churning|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664196/|journal=Health affairs (Project Hope)|volume=34|issue=7|pages=1180–1187|doi=10.1377/hlthaff.2014.1204|issn=0278-2715|pmc=4664196|pmid=26153313|via=}}</ref><ref>{{Cite web|url=https://familiesusa.org/sites/default/files/product_documents/Return_of_Churn_Analysis.pdf|title=The Return of Churn: Families USA Report|last=|first=|date=2019-08-20|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>.  Further, if the agencies responsible do not coordinate effectively, there can be coverage gaps, if one kind of coverage is stopped before the other starts.  There can also be abrupt switches of coverage class, which can void in-network hospitalizations and surgeons and approved procedures.

The issue of the importance and delicacy of coordination between agencies on these matters was brought out early after the approval of the ACA.<ref>{{Cite web|url=http://www.thalassemia.org/updates/pdf/HealthInsuranceExchanges.pdf|title=HEALTH INSURANCE EXCHANGES AND THE AFFORDABLE CARE ACT: KEY POLICY ISSUES (see "Administering Subsidies and Mandates" on adobe p. 6)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://www.shadac.org/sites/default/files/Old_files/shadac/publications/EligibilityChangesStateIssues_Brief1.pdf|title=Implementing Eligibility Changes under the Affordable Care Act: Issues Facing State Medicaid and CHIP Programs (see pp. 3-4)|last=|first=|date=2019-08-10|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=http://web.archive.org/web/20190811012145/https://webcache.googleusercontent.com/search?q=cache:OehcPw7YXkgJ:https://www.nhchc.org/wp-content/uploads/2011/09/Kaiser-Medicaid-enroll-regs-Oct-2011.pdf+&cd=1&hl=en&ct=clnk&gl=us|title=Medicaid Eligibility, Enrollment Simplification, and Coordination under the Affordable Care Act: A Summary of CMS's August 17, (See p. 6)|last=|first=|date=2019-08-11|website=web.archive.org|archive-url=|archive-date=|dead-url=|access-date=2019-08-11}}</ref>.  Indeed, a 2015 GAO report found problems in continuity of coverage in synching state Medicaid eligibility with the Federal exchange's on-exchange plans, in states that used the Federal exchange<ref>{{Cite web|url=https://www.gao.gov/assets/680/673026.pdf|title=GAO Report Oct 2015: MEDICAID AND INSURANCE EXCHANGES Additional Federal Controls Needed to Minimize Potential for Gaps and Duplication in Coverage|last=|first=|date=2019-08-15|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>. 
==Public opinion==
Prior to the law's passage, polling indicated the public's views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Polling statistics showed a general negative opinion of the law; with those in favor at approximately 40% and those against at 51%, as of October 2013.<ref name="rcp"/><ref name="swanson"/> Democrats favored the law, Republicans strongly opposed it, and self-identified independents were divided.<ref>{{Cite journal|last=Dijulio|first=Bianca|last2=Kirzinger|first2=Ashley|last3=Hamel|first3=Elizabeth C.|last4=Brodie|first4=Mollyann|title=Partisanship, Polling, and the Affordable Care Act|journal=Public Opinion Quarterly|language=en|doi=10.1093/poq/nfz016|year=2019}}</ref> About 29% of [[Non-Hispanic whites|whites]] approved of the law, compared with 61% of [[Hispanic and Latino Americans|Hispanics]] and 91% of [[African American]]s.<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 |publisher=Pew Research Center |date=September 16, 2013}}</ref> Opinions were divided by age of the person at the law's inception, with a solid majority of seniors opposing the bill and a solid majority of those younger than forty years old in favor.<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>

[[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 celebrating the 6th anniversary of the Affordable Care Act in March 2016 on the steps of the U.S. Capitol]]
Specific elements were popular across the political spectrum, while others, such as the mandate to purchase insurance, were widely disliked. In a 2012 poll 44% supported the law, with 56% against. By party affiliation, 75% of Democrats, 27% of Independents and 14% of Republicans favored the law overall. 82% favored banning insurance companies from denying coverage to people with pre-existing conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.<ref name=most/> Other polls showed additional provisions receiving majority support, including the creation of insurance exchanges, pooling small businesses and the uninsured with other consumers so that more people can take advantage of large group pricing benefits and providing subsidies to individuals and families to make health insurance more affordable.<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>

In a 2010 [[Opinion poll|poll]], 62% of respondents said they thought ACA would "increase the amount of money they personally spend on health care", 56% said the bill "gives the government too much involvement in health care", and 19% said they thought they and their families would be better off with the legislation.<ref>{{cite news |url=http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf |title=CNN Opinion Research Poll |publisher=CNN |date=March 22, 2010}}</ref> Other polls found that people were concerned that 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 |work=The Wall Street Journal |first1=Scott |last1=Rasmussen |first2=Doug |last2=Schoen |title=Why Obama Can't Move the Health-Care Numbers |date=March 9, 2010}}</ref>

Some opponents believed that the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.<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 [[Michael Moore]] & [[Charles Krauthammer]] comments - seems consistent with [[Talk:Patient Protection and Affordable Care Act#Does an individual's opinion belong in the Public Opinion section?|talk]]
American filmmaker, author, [[social critic]] and political activist [[Michael Moore]] criticized the ACA by saying that 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>
--->A 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA vs. 38.3% who had a favorable view (of more than 5,500 individuals).<ref>{{cite web |url=https://www.rand.org/health/projects/health-reform-opinion.html |title=RAND Health Reform Opinion Study |publisher=RAND Health |date=May 1, 2014 |accessdate=May 10, 2014}}</ref>

A 2014 poll reported that 26% of Americans support ACA.<ref>{{cite news |url=http://bigstory.ap.org/article/poll-obama-health-law-fails-gain-support |title=AP-GfK Poll: Obama's health care fails to gain support |publisher=Associated Press |date=March 28, 2014 |accessdate=March 30, 2014}}</ref> Another held that 8% of respondents say that 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 Reports|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 [[CBS News]] / [[New York Times]] poll reported that 47% of Americans approved the health care law. This was the first time that a major poll indicated that more respondents approved ACA than disapproved of it.<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> The recurring [[Kaiser Family Foundation|Kaiser Health Tracking Poll]] from December 2016 reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.<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 opposed it in the past (many prefer a "Medicare for All" approach) have shifted their positions since the ACA is 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>

A January 2017 Morning Consult poll showed that 35% of respondents either believed that "Obamacare" and the "Affordable Care Act" were different or did not know.<ref name=":1">{{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=2017-02-07 |newspaper=The New York Times|access-date=2017-02-08 |last2=Nyhan |first2=Brendan |issn=0362-4331}}</ref> Approximately 45% were unsure whether the "repeal of Obamacare" also meant the "repeal of the Affordable Care Act."<ref name=":1" /> 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 name=":1" />

A 2017 study found that personal experience with public health insurance programs leads to greater support for the Affordable Care Act, and the effects appear to be most pronounced among Republicans and low-information voters.<ref>{{Cite journal |last=Lerman |first=Amy E. |last2=McCabe |first2=Katherine T. |date=2017-01-24 |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 used it in a health industry journal, writing "We will soon see a '[[Rudy Giuliani|Giuliani]]-care' and 'Obama-care' to go along with '[[John McCain|McCain]]-care', '[[John Edwards|Edwards]]-care', and a totally revamped and remodeled '[[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"/> It first appeared in a political campaign by [[Mitt Romney]] in May 2007 in [[Des Moines, Iowa]]. Romney said, "[[Massachusetts health care reform|In my state, I worked on healthcare for some time.]] We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over healthcare?' And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."<ref name="CNN20120625Obamacare"/>

By mid-2012, Obamacare had become the colloquial term used by both supporters and opponents. In contrast, the use of "Patient Protection and Affordable Care Act" or "Affordable Care Act" became limited to more formal and official use.<ref name="NYT20120803"/> Use of the term in a positive sense was suggested by Democrat [[John Conyers]].<ref>{{cite web|first1=Ashley|last1=Perks|accessdate=2019-08-27|title=President embraces ObamaCare label|url=https://thehill.com/policy/healthcare/185877-president-embraces-obamacare-label|date=6 October 2011|website=[[The Hill (newspaper)|The Hill]]}}</ref> 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>

In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post [[Twitter]] messages that begin, "I like #Obamacare because ...".<ref name="thehill"/>

In October 2013, the [[Associated Press]] and [[NPR]] began cutting back on use of the term.<ref>{{cite web |last=Prince |first=Richard |url=http://mije.org/richardprince/ap-npr-curb-use-obamacare-term |title=AP, NPR Curb Use of "Obamacare" Term |publisher=Robert C. Maynard Institute for Journalism Education |date=October 2, 2013 |accessdate=October 5, 2013 |deadurl=yes |archiveurl=https://web.archive.org/web/20131005231540/http://mije.org/richardprince/ap-npr-curb-use-obamacare-term |archivedate=October 5, 2013 |df=mdy-all }}</ref> Stuart Seidel, NPR's managing editor, said that the term "seems to be straddling somewhere between being a politically-charged term and an accepted part of the vernacular".<ref>{{cite web |last=Gold |first=Hadas |authorlink=Hadas Gold|title=AP, NPR to cut back on 'Obamacare' |url=http://www.politico.com/blogs/media/2013/10/ap-npr-to-cut-back-on-obamacare-174305.html |work=Politico |date=October 4, 2013 |accessdate=October 19, 2013}}</ref>

===Common misconceptions===
<!-- NOTE: A "common misconception" is (1) a false or fringe view about the PPACA ("misconception") (2) that is commonly believed among the general public ("common"). Views included in this section must be supported by citations to reliable, neutral, secondary sources that show that these criteria are satisfied. Please discuss on the talk page before making major changes to this section. For information on false/fringe views and why Wikipedia presents them as factually incorrect, please read WP:UNDUE and WP:FRINGE -->

===="Death panels"====
{{Main|Death panel|}}
On August 7, 2009, [[Sarah Palin]] pioneered the term "[[death panel]]s" to describe groups that 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 |publisher=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 the statutory levels set for Medicare were exceeded within any given 3-year period. In fact, the Board was prohibited from recommending changes that would reduce payments to certain providers before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.<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 health care directive|advance-care planning]] consultation: [[HR 3200#Reimbursement for counseling about living wills|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 ACA.<ref name="SenateCommittee">{{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> A poll in August 2012 found that 39% of Americans believed the claim.<ref>{{cite news |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/258753-poll-four-in-10-believe-in-health-law-death-panels |title=Poll: Four in 10 believe in Obama healthcare law 'death panels{{'-}}|work=The Hill|date=September 26, 2012|first=Elise|last=Viebeck}}</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====
ACA requires members of Congress and their staffs to obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the insurance offered to federal employees (the [[Federal Employees Health Benefits Program]]).<!-- FEHBP no longer exists for federal retirees?; please clarify --><ref name="CongressionalInsurance">[http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm Public Law 111 – 148], section 1312: "... the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."</ref><ref>{{cite web |first=Jonathan |last=Chait |url=http://nymag.com/daily/intelligencer/2013/08/congress-exempt-from-obamacare-or-something.html |title=Congress Exempts Itself From Obamacare! Or Something! |work=New York |date=August 6, 2013}}</ref><ref>{{cite web |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/114284/congress-exempt-obamacare-latest-lie-wont-die |title=The Latest Obamacare Lie That Just Won't Die |work=The New Republic |date=August 13, 2013}}</ref><ref>{{Cite news |title=Sen. Ted Cruz says Obama 'just granted all of Congress an exception' to Obamacare |publisher=PolitiFact |date=August 14, 2013 |url=http://www.politifact.com/truth-o-meter/statements/2013/aug/14/ted-cruz/sen-ted-cruz-says-obama-just-granted-all-congress- |first=Becky |last=Bowers |accessdate=August 19, 2013}}</ref><ref>{{Cite news |title=Congress Exempt from Health Bill? |first=Lori |last=Robertson |publisher=[[FactCheck.org]] |date=January 20, 2010 |url=http://www.factcheck.org/2010/01/congress-exempt-from-health-bill}}</ref>

====Illegal immigrants====
ACA does not provide benefits to illegal immigrants.<ref>{{cite news |last=Viebeck |first=Elise |title=Poll: Four in 10 think illegals are covered by Obama healthcare law |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/285089-poll-four-in-10-think-illegals-are-covered-by-obamacare |newspaper=The Hill |date=February 27, 2013 |accessdate=December 7, 2013}}</ref> It 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|Affordable Care Act (ObamaCare). County By County Projected Insurer Participation in Health Insurance Exchanges.]]
One argument against the ACA is that the insurers are leaving the marketplaces, as they cannot profitably cover the available pool of customers, which contains too many unhealthy participants relative to healthy participants. A scenario where prices rise, due to an unfavorable mix of customers from the insurer's perspective, resulting in fewer customers and fewer insurers in the marketplace, further raising prices, has been called a "death spiral."<ref name=MM_1>{{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 |publisher=Bloomberg |date=January 18, 2017}}</ref> During 2017, the median number of insurers offering plans on the ACA exchanges in each state was 3.0, meaning half the states had more and half had fewer insurers. There were five states with one insurer in 2017; 13 states with two; 11 states with three; and the remainder had four insurers or more. Wisconsin had the most, with 15 insurers in the marketplace. The median number of insurers was 4.0 in 2016, 5.0 in 2015, and 4.0 in 2014.<ref name=Kaiser_Insurers>{{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>

Further, the CBO reported in January 2017 that it expected enrollment in the exchanges to rise from 10 million during 2017 to 13 million by 2027, assuming laws in place at the end of the Obama administration were continued.<ref name="CBO_BEO2017">{{Cite web |url=https://www.cbo.gov/publication/52370 |title=CBO The Budget and Economic Outlook 2017–2027 |publisher=CBO |date=24 January 2017}}</ref> Following a 2015 CBO report that reached a similar conclusion, [[Paul Krugman]] wrote: "But the truth is that this report is much, much closer to what supporters of reform have said than it is to the scare stories of the critics—no death spirals, no job-killing, major gains in coverage at relatively low cost."<ref name=Krugman_ACA2015>{{cite news |url=https://krugman.blogs.nytimes.com/2015/06/20/obamacare-and-labor-supply/ |title=Obamacare and Labor Supply |newspaper=New York Times |date=June 20, 2015}}</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/> [[Conservatism in the United States|conservative]] advocacy groups,<ref name="NYT-20131018"/><ref name="NYT-20140126"/> Republicans, small business organizations and the [[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 that 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]] has 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=25 January 2017 |work=The New York Times |date=10 January 2017}}</ref>

{{As of|2013}} unions that expressed concerns about ACA included the [[AFL-CIO]],<ref name=AFLCIO/> which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the [[International Brotherhood of Teamsters]], [[United Food and Commercial Workers International Union]], and [[UNITE-HERE]], whose leaders sent a letter to Reid and Pelosi arguing, " ACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class."<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|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 that the ACA had "many good features" but that it was "no longer affordable for increasing numbers of people" and called on the Minnesota legislature to provide emergency relief to policyholders.<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===
{{Main|Constitutional challenges to the Patient Protection and Affordable Care Act}}
{{See also|National Federation of Independent Business v. Sebelius|King v. Burwell|Efforts to repeal the Patient Protection and Affordable Care Act}}

====''National Federation of Independent Business v. Sebelius''====
Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds.<ref>{{cite web |last=Cauchi |first=Richard |title=State Legislation and Actions Challenging Certain Health Reforms |url=http://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx |publisher=National Conference of State Legislatures |date=November 15, 2013 |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}} In ''[[National Federation of Independent Business v. Sebelius]]'', the Supreme Court ruled on a 5–4 vote that the individual mandate was constitutional when viewed as a tax, although [[Constitutional challenges to the Patient Protection and Affordable Care Act#U.S. Supreme Court|not]] under the [[Commerce Clause]].

The Court further determined that states could not be forced to participate in the Medicaid expansion. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.<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 ACA's objectives, voiced concern through the [[USCCB|United States Conference of Catholic Bishops]] that aspects of the mandate covering contraception and sterilization and [[United States Department of Health and Human Services|HHS]]'s narrow definition of a religious organization violated the [[First Amendment to the United States Constitution|First Amendment]] right to [[Free Exercise Clause|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>

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=http://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'' ====
In ''[[United States House of Representatives v. Price]]'' (previously ''United States House of Representatives v. Burwell'') 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. The ACA 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 name=":20">{{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| author-link = Greg Sargent |title=Trump's latest tantrum will hurt hundreds of thousands of people. Here's how. |newspaper=[[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 = 2017-05-29}}</ref>

==== ''Texas et al v. United States of America et al'' ====
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 eliminate the tax penalty for not having health insurance starting January 1, 2019, the constitutionality of the individual mandate that formed the basis of the ACA, as determined in ''National Federation of Independent Business'', was no longer valid, and thus the entire ACA was no longer constitutional.<ref>[https://www.courtlistener.com/recap/gov.uscourts.txnd.299449/gov.uscourts.txnd.299449.1.0.pdf]</ref> During the prosecution of the case, the Justice Department said it would no longer defend the ACA in court, but seventeen states led by California stepped in to defend it.<ref name="cnn 20181214"/>

District judge [[Reed O'Connor]] of Texas ruled in favor of 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 inseverable, leading to declaring 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=2018-12-14|website=TheHill|language=en|access-date=2018-12-15}}</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 record during the ACA debate that focused on the importance of the mandate in supporting the healthcare marketplace.<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 O'Connor ruled the law unconstitutional, he did not declare the law overturned with this decision.<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> Through Twitter messages following the decision, President Trump urged Congress, particularly [[Mitch McConnell]] and [[Nancy Pelosi]], to enact a replacement for the ACA with stronger protections for pre-existing conditions.<ref name=":3">{{Cite web|url=https://twitter.com/realDonaldTrump/status/1073761497866747904|title=As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster! Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!|last=Trump|first=Donald J.|date=2018-12-14|website=@realDonaldTrump|language=en|access-date=2018-12-15}}</ref><ref>{{Cite web|url=https://thehill.com/homenews/administration/421517-trump-calls-on-mitch-and-nancy-to-pass-healthcare-law-after-obamacare|title=Trump touts ruling against ObamaCare: 'Mitch and Nancy' should pass new health-care law|last=Axelrod|first=Tal|date=2018-12-14|website=TheHill|language=en|access-date=2018-12-15}}</ref>

California and the other Democratic states appealed the decision to the [[United States Court of Appeals for the Fifth Circuit]], following the decision by the Department of Justice to step away from defending the ACA. These states argued that Congress's change in the tax penalty from the Tax Cuts and Jobs Act of 2017 was only reducing the amount of the penalty, and if Congress wanted to revoke the entire ACA, they had the power to write a stronger law to this end.<ref name="cnn 20190708"/><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 = [[The Washington Post]] }}</ref> O'Connor wrote in a December 30, 2018 order that his decision is to be held back while such appeals are in progress, allowing the ACA to continue to be used after January 1, 2019.<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 Texas and other Republican states to rule ACA unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. Several other health care groups involved in prior ACA debates also joined on respective sides of this case.<ref name="cnn 20190708">{{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 | first=  Joan | last = Biskupic | date = July 8, 2019 | accessdate = July 8, 2019 | work = [[CNN]] }}</ref>  It is expected that this case will eventually return to the Supreme Court.<ref name="wapost 20181214"/> In addition to the questions on the ACA, an additional question on [[Standing (law)|standing]] was addressed, as the Republican plaintiffs have challenged whether the Democratic states have standing to defend the ACA.<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 = [[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 = [[The New York Times]] }}</ref>

====Non-cooperation====
Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements of ACA 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 [[Delay in application of the Individual Health Insurance Mandate|establish a health insurance marketplace]] engaging in active [[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 Republican politicians discouraged efforts to advertise the benefits of the law. 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===
{{Main|Efforts to repeal the Patient Protection and Affordable Care Act}}
ACA was the subject of unsuccessful repeal efforts by [[Republican Party (United States)|Republicans]] in the [[111th United States Congress|111th]], [[112th United States Congress|112th]], and [[113th United States Congress|113th]] Congresses: Representatives [[Steve King]] (R-IA) and [[Michele Bachmann]] (R-MN) introduced bills in the House to repeal ACA the day after it was signed, as did Senator [[Jim DeMint]] (R-SC) in the Senate.<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 3 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> House Democrats proposed an amendment that repeal not take effect until a majority of the Senators and Representatives had opted out of the [[Federal Employees Health Benefits Program]]; Republicans voted down the measure.<ref>{{cite web |last=Beutler |first=Brian |title=Dems Press GOPers To Repeal Their Own Benefits Along With Health Care Law |publisher=[[Talking Points Memo]] |date=January 19, 2011 |url=http://tpmdc.talkingpointsmemo.com/2011/01/dems-press-gopers-to-repeal-their-own-benefits-along-with-health-care-law.php?ref=dcblt |accessdate=January 21, 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 had stated that he would have [[U.S. Presidential veto|vetoed]] the bill even if it had passed both chambers of Congress.<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=[[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 |dead-url=yes |df=mdy-all }}</ref>
[[File:2017 House budget.pdf|thumb|2017 House Budget]]
Following the [[#Legal challenges|2012 Supreme Court ruling]] upholding ACA as constitutional, Republicans held another vote to repeal the law on July 11;<ref>{{cite news |url=https://www.wsj.com/articles/SB10001424052702303561504577494682627914026 |title=Romney, GOP Pledge to Repeal Health Law |last=Boles |first=Corey |newspaper=The Wall Street Journal |date=June 28, 2012 |accessdate=June 29, 2012}}</ref> the House of Representatives voted with all 244 Republicans and 5 Democrats in favor of repeal, which marked the 33rd, partial or whole, repeal attempt.<ref name="thirtythree"/><ref name="thirtyone"/> 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 accompanied with a delay in ACA implementation, after the President unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership stated the Senate would only pass a "clean" funding bill without any restrictions on ACA. The [[United States federal government shutdown of 2013|government shutdown]] began on October 1.<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=[[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=[[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> Senate Republicans threatened to block appointments to relevant agencies, such as the Independent Payment Advisory Board<ref>{{cite web |last=Goddard |first=Teagan |title=Blocking the Medicare Reform Board Won't Stop Reform |url=http://wonkwire.rollcall.com/2013/05/17/blocking-the-medicare-reform-board-wont-stop-reform/ |publisher=WonkWire.RollCall.com |date=May 17, 2013 |deadurl=yes |archiveurl=https://web.archive.org/web/20130921055215/http://wonkwire.rollcall.com/2013/05/17/blocking-the-medicare-reform-board-wont-stop-reform/ |archivedate=September 21, 2013 |df=mdy-all }}</ref> and [[Centers for Medicare and Medicaid Services]].<ref>{{cite news |last=Cohn |first=Jonathan |title=Save Donald |url=https://newrepublic.com/article/politics/75324/save-donald |work=The New Republic |date=May 24, 2010}}<br />{{cite news |last=Cohn |first=Jonathan |title=Meet The Don |url=https://newrepublic.com/blog/jonathan-cohn/76076/meet-the-don |work=The New Republic |date=July 6, 2010}}</ref><ref>{{cite news |last=Cohn |first=Jonathan |title=The New Nullification: GOP v. Obama Nominees |url=https://newrepublic.com/blog/jonathan-cohn/92167/cordray-warren-cfpb-obama-republicans-nomination |work=The New Republic |date=July 19, 2011}}</ref>

====2017 repeal effort====
{{Main|2017 Patient Protection and Affordable Care Act replacement proposals}}
During a midnight congressional session starting January 11, 2017, the Senate of the [[115th United States Congress|115th Congress of the United States]] voted to approve a "budget blueprint" which would allow [[Republican Party (United States)|Republicans]] to repeal parts of the law "without threat of a [[Democratic Party (United States)|Democratic]] [[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=12 January 2017 |work=The New York Times |last2=Pear |first2=Robert|access-date=12 January 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=11 January 2017 |work=Fox News Politics|access-date=12 January 2017 |via=}}</ref> The plan, which passed 51–48, is a budget blueprint 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=12 January 2017 |work=CNN |last2=Barrett |first2=Ted |last3=LoBianco |first3=Tom|access-date=12 January 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=12 January 2017 |work=NBC News|access-date=12 January 2017 |via=}}</ref>

[[Republican Conference of the United States House of Representatives|House Republicans]] announced their replacement for the ACA, the [[American Health Care Act]], on March 6, 2017.<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, 2017 the effort, led by [[Paul Ryan]] and [[Donald Trump]], to repeal and replace the ACA failed amid a revolt among Republican representatives.<ref name="170324Pear">{{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=24 March 2017 |newspaper=[[New York Times]] |date=24 March 2017}}</ref>

May 4, 2017, the United States House of Representatives voted to pass the American Health Care Act (and thereby repeal most of the Affordable Care Act) by a narrow margin of 217 to 213, sending the bill to the Senate for deliberation.<ref name="CNN-passage">{{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}}</ref>

The Senate process began with an unprecedented level of secrecy; [[Party leaders of the United States Senate|Senate Majority Leader]] [[Mitch McConnell]] named a group of 13 Republican Senators to draft the Senate's substitute version in private, raising bipartisan concerns about a lack of transparency.<ref name="nyt-secrecy">{{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 |deadurl=no |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 |df=mdy-all}}</ref><ref name="wapo-remarkable">{{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 |deadurl=no |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 |df=mdy-all}}</ref><ref name="shrouded">{{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 |deadurl=no |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 |df=mdy-all}}</ref> On June 22, 2017, Republicans released the first discussion draft for an amendment to the bill, which would rename it to the "Better Care Reconciliation Act of 2017" (BCRA).<ref name="BCRA_ERN17282">{{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, 2017, although no amendment proposal had yet garnered majority support, Senate 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 |first=Lauren Fox, MJ Lee, Phil Mattingly and Ted Barrett |last=CNN |website=CNN |deadurl=no |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 |df=mdy-all}}</ref>

All specific bills were defeated, however. The revised BCRA failed on a vote of 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but failed on a vote of 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to the ACA, failed by 49–51, with Collins, Murkowski, and Senator [[John McCain]] joining all the Democrats and independents in voting against it.<ref>{{Citation |last=Klein |first=Ezra | author-link = Ezra Klein |title=The GOP's massive health care failures, explained |publisher=[[Vox (website)|Vox]] |date=July 28, 2017 |url=https://www.vox.com/health-care/2017/7/28/16055284/gop-massive-health-care-failures-explained | access-date = 2017-08-03}}</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 name="Rattner_Charts">{{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 the ACA (current law) and the AHCA, CBO reported that the health exchange marketplaces would remain stable (i.e., no "death spiral").<ref name=CBO_Score1 /> However, Republican politicians have taken a variety of steps to undermine it, creating uncertainty that has 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> Insisting the exchanges are in difficulty was also used as an argument for passing reforms such as AHCA or BCRA. Past and ongoing Republican attempts to weaken the law have included, among others:
* Lawsuits such as ''[[King v. Burwell]]'', which resulted in a decision by the Supreme Court that limited Medicaid expansion but upheld the mandates and insurance subsidies. According to the [[Kaiser Family Foundation]], not expanding Medicaid in 19 states has increased the number uninsured by an estimated 4.5 million persons.<ref name="Kaiser_Gap"/>
* Lawsuits pending (''[[House v. Price]]'') such as whether cost-sharing subsidies must be paid. President Trump threatened not to pay these subsidies in early 2017 and later decided to stop paying them. 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>
* Prevention of appropriations for transitional financing ("risk corridors") to steady insurance markets, resulting the bankruptcy of many co-ops offering insurance. This action was attributed to Senator Marco 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>
* Weakening of the individual mandate through his first executive order, which resulted in limiting enforcement of mandate penalties by the IRS. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding instructions from the Obama administration to the IRS 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>
* Reduction to funding for advertising for the 2017 and 2018 exchange enrollment periods 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 in September 2017 that the reductions would lead to reduced ACA enrollment.<ref name="VoxCBO1"/>
* The Trump administration reduced the enrollment period for 2018 by half, to 45 days. The NYT editorial board referred to this as part of a concerted "sabotage" effort.<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>
* Public statements by Trump that the exchanges are unstable or in a [[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>
* Trump's October 12, 2017 [[executive order]] and a related action the same day ending federal subsidies of questionable legality<ref>{{cite news |url=https://www.npr.org/sections/health-shots/2017/10/13/557541856/halt-in-subsidies-for-health-insurers-expected-to-drive-up-costs-for-middle-clas |title=Halt In Subsidies For Health Insurers Expected To Drive Up Costs For Middle Class |last=Kodjak |first=Alison |agency=[[NPR]] |date=October 13, 2017 |accessdate=October 18, 2017}}</ref> used to help those buying insurance through exchanges with their co-payments and deductibles. About 6 million people were helped at a cost of $7 billion a year but that amount was expected to double in 10 years. State officials claimed the action caused insurance premiums to go up dramatically. Many states sued in federal court on the grounds that Trump was not legally allowed to take the action.<ref>{{cite news |url=http://www.journalnow.com/news/state_region_ap/many-states-consumers-alarmed-by-trump-s-health-care-order/article_ae739354-22f7-5998-9ac7-53f0fe029442.html |archive-url=https://web.archive.org/web/20171019055306/http://www.journalnow.com/news/state_region_ap/many-states-consumers-alarmed-by-trump-s-health-care-order/article_ae739354-22f7-5998-9ac7-53f0fe029442.html |dead-url=yes |archive-date=October 19, 2017 |title=Many states, consumers alarmed by Trump's health care order |last1=Mulvihill |first1=Geoff |last2=Kennedy |first2=Kelli |work=[[Winston-Salem Journal]] |agency=[[Associated Press]] |date=October 13, 2017 |accessdate=October 18, 2017 }}</ref>
* Several insurers and actuary groups cited uncertainty created by President Trump, specifically non-enforcement of the individual mandate and not funding cost sharing reduction subsidies, as contributing 20–30 percentage points to premium increases for the 2018 plan year on the ACA exchanges. In other words, absent Trump's actions against the ACA, premium increases would have averaged 10% or less, rather than the estimated 28–40% under the uncertainty his actions created.<ref name="VoxDS1">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>
* The progressive think tank [[Center on Budget and Policy Priorities]] (CBPP) maintains a timeline of many "sabotage" efforts by the Trump Administration.<ref>[https://www.cbpp.org/sabotage-watch-tracking-efforts-to-undermine-the-aca "Sabotage Watch: Tracking Efforts to Undermine the ACA"]. [[Center on Budget and Policy Priorities]]. Updated October 12, 2017. Retrieved October 19, 2017.</ref>

===Ending cost-sharing reduction (CSR) payments===
{{Main|Cost sharing reductions subsidy}}
President Trump announced on October 12, 2017,<ref name=":43">Pear, Robert; Haberman, Maggie; Abelsonoct, Reed (October 12, 2017). [https://www.nytimes.com/2017/10/12/us/politics/trump-obamacare-executive-order-health-insurance.html?_r=0 "Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again"]. ''[[The New York Times]]''.</ref> he would end the smaller of the two types of subsidies under the ACA, the cost sharing reduction (CSR) subsidies. This controversial decision significantly raised premiums on the ACA exchanges along with the premium tax credit subsidies that rise with them, with the CBO estimating a $200 billion increase in the budget deficit over a decade. The reasons for this are complex and require discussion of how the two major subsidies work.<ref name="Vox1SK">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 CSR subsidies are paid to insurance companies to reduce copayments and deductibles for a smaller group of ACA enrollees, those earning less than 250% of the federal poverty line (FPL). The second and larger type of subsidy, the premium tax credits designed to reduce the post-subsidy cost of monthly premiums, apply to all enrollees earning less than 400% of the FPL. For scale, during 2017, approximately $7 billion in CSR subsidies will be paid, versus $34 billion for the premium tax credits.<ref name="CBOSubsidy17">[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> A court decision meant that CSR subsidies were treated as discretionary spending, meaning Congress must decide to appropriate funds for them each year. This effectively gave the President the power to end them, as Democrats with a minority in Congress could not appropriate the funds, let alone override his veto of an appropriations bill.<ref name="Vox1SK"/>

However, the premium tax credits are mandatory spending, meaning all those eligible under the ACA receive them without Congressional appropriation. These adjust with premium increases to limit after-subsidy premium payments by ACA enrollees to a fixed percentage of income. Based on President Trump's threats to end the CSR payments during early 2017, 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 name="VoxDS1"/><ref name="Vox1SK"/>

The CBO reported in August 2017 (prior to President Trump's decision) that ending the CSR payments might increase ACA premiums by 20 percentage points or more, with a resulting increase of nearly $200 billion in the budget deficit over a decade, as the premium tax credit subsidies would rise along with premium prices. CBO also estimated that initially up to one million fewer would have health insurance coverage, although more might have it in the long-run as the subsidies expand. 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 name="CBO-CSR1">[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>

CBO estimated that of the 12 million with private insurance via the ACA exchanges in 2017, about 10 million receive premium tax credit subsidies and will be shielded from premium increases, as their after-subsidy premiums are limited as a percentage of income under the ACA.  (In fact, due to a new practice initiated by the states of "silver loading" -- see next paragraph -- some of those people with incomes from 250% to 400% of FPL get lower cost bronze, gold, and platinum plans than they would have before the Trump action.)

There was the possibility that those 2 million who do not receive subsidies face the brunt of the 20%+ premium increases, without subsidy assistance. This could potentially have adversely impacted enrollment in 2018 and beyond.  However, many states countered the Trump move by either directing, or allowing, insurance companies to assess the actuarial costs of the lost CSR payments to silver plans only, or sometimes, to silver plans purchased on the exchange only.<ref name=":29" /><ref name=":28" /> (The practice was called "silver loading".) 

Where there is silver loading, the effect is to often give people who received premium subsidies who purchased silver plans, roughly the same net-of-premium-subsidy costs as before the Federal payments were stopped. (This is because premium subsides are determined by a formula to make the second lowest cost silver plan cost a certain fixed percentage of MAGI, so that the increased premiums were accompanied by a commensurately increased subsidy.)

Further, where there is silver loading, premiums for bronze, gold, and platinum plans are unchanged.  (So a person not receiving a subsidy could avoid increased costs by avoiding silver plans.) 

(Note that it may be possible for a Presidential administration to ban silver loading in the future, so in that case, the consequences of the lost CSR payments would be more severe.)<ref name=":28" />

Another 13 million who are covered under the ACA's Medicaid expansion (in the 31 states that chose to expand coverage) were not directly affected by Trump's action.<ref name="CBO-CSR1" /><ref name="CBOSubsidy17" />

President Trump's argument that the CSR payments were a "bailout" for insurance companies and therefore should be stopped, actually results in the government paying more to insurance companies ($200B over a decade) due to increases in the premium tax credit subsidies.<ref name="Vox1SK"/>

==Implementation==
{{Main|Implementation history of the Patient Protection and Affordable Care Act}}
At various times during and after the ACA debate, Obama stated that "if you like your health care plan, you'll be able to keep your health care plan".<ref>{{cite web |title=A Town Hall, and a Health Care Model, in Green Bay |url=http://www.whitehouse.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay |publisher=The White House Blog |accessdate=November 9, 2013 |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 |dead-url=yes |df=mdy-all }}</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 |title=After the big Obamacare apology: where things stand |url=http://www.cnn.com/2013/11/08/politics/obama-obamacare-apology |publisher=CNN |date=November 8, 2013 |accessdate=November 9, 2013}}</ref> and several million more risked seeing their current plans cancelled.<ref>{{cite web |url=http://www.cnn.com/2013/11/07/politics/obama-obamacare-apology |title=Obama apologizes for insurance cancellations due to Obamacare |publisher=CNN |date= |accessdate=July 29, 2014}}</ref><ref>[https://www.reuters.com/article/2013/10/30/us-usa-healthcare-sebelius-idUSBRE99T0PN20131030 Obama blames 'bad apple' insurers for canceled coverage], Reuters.com, October 30, 2013.</ref><ref>{{cite news |first=Ed |last=Sealover |title=Health insurers say they're canceling plans because of federal law |url=http://www.bizjournals.com/denver/news/2013/11/08/health-insurers-canceling-plans-say.html |work=Denver Business Journal |date=November 8, 2013 |accessdate=November 9, 2013}}</ref> However, Poltifact cited various estimates that only about 2% of the total insured population (4 million out of 262 million) received such notices.<ref>{{cite news |title=Lie of the Year: "If you like your health care plan, you can keep it|url=http://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/|publisher=Politifact |date=December 12, 2014|accessdate=April 5, 2018}}</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 |first=David |last=Weigel |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 |title=The White House's Website Still Says If You Like Your Plan You Can Keep It |magazine=Slate |date=November 8, 2013 |accessdate=November 9, 2013}}</ref><ref>{{cite news |title=Obamacare: The debacle |url=https://www.economist.com/news/united-states/21588951-congress-hears-tales-baffling-ineptitude-debacle |work=[[The Economist]] |date=November 2, 2013 |accessdate=November 8, 2013}}</ref> On November 7, 2013, President Obama stated: "I am sorry that [people losing their plans] are finding themselves in this situation based on assurances they got from me."<ref>{{cite news |title=Obama apologizes to Americans who lost health plans |url=http://www.foxnews.com/politics/2013/11/08/bipartisan-bill-to-delay-individual-mandate-introduced-as-obama-apologizes-over |publisher=Fox News |date=November 8, 2013 |accessdate=November 9, 2013}}</ref> Various bills were introduced in Congress to allow people to keep their plans.<ref>{{cite news |last=Schoof |first=Renee |title=Congress weighing laws to let people keep health insurance |url=http://www.mcclatchydc.com/2013/11/08/207999/congress-weighing-laws-to-let.html |publisher=McClatchyDC |date=November 8, 2013 |accessdate=November 14, 2013}}</ref>

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|Pre-Existing Condition Insurance Plan]] (PCIP) took effect to offer insurance to those that had been denied coverage by private insurance companies because of a pre-existing condition.<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]]'' decided on June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional when the associated penalties were construed as a tax. The decision allowed states to opt out of the Medicaid expansion.<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=5 May 2017}}</ref>

In 2013, the [[Internal Revenue Service]] ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold.<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> In July 2 it was announced the implementation of the employer mandate would be delayed until 2015.<ref name="CohnDelay" /><ref name="treasurystatement" /><ref name="REG-138006-12" /> The launch for both the state and federal exchanges was troubled due to management and technical failings. [[HealthCare.gov]], the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered endless problems.<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 [[Government Accountability Office]] released a non-partisan study in 2014 that concluded that the administration did not provide "effective planning or oversight practices" in developing the ACA website.<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> The December spending bill delayed the onset of the "[[Cadillac tax]]" on expensive insurance plans by two years, 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> In January 2018, the implementation of the "Cadillac Tax" was postponed until 2022.

An estimated 9 million to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults.<ref name=":10" /> A survey of New York businesses found an increase of 8.5 percent in health care costs, less than the prior year's survey had expected.<ref>{{Cite web |url=https://www.newyorkfed.org/medialibrary/media/survey/business_leaders/2016/2016_08supplemental.pdf?la=en |title=Supplemental Survey Report: Empire State Manufacturing Survey/Business Leaders Survey Firms Assess Effects of Affordable Care Act |last= |first= |date=August 2016 |website= |publisher=Federal Reserve Bank of New York |accessdate=}}</ref> The five major national insurers expected to lose money on ACA policies in 2016.<ref>{{Cite news |url=https://www.wsj.com/articles/aetna-to-drop-some-affordable-care-act-markets-1471311737 |title=Aetna to Drop Some Affordable Care Act Markets |last=Mathews |first=Anna Wilde |date=August 16, 2016 |newspaper=Wall Street Journal |issn=0099-9660 |accessdate=August 16, 2016}}</ref> One of the causes of insurer losses is the lower income, older and sicker enrollee population.<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 signed up for care on the national exchange (healthcare.gov) for 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump.<ref name=ACA_NYT2017/> Of the 9.2 million, 3.0 million were new customers and 6.2 million were returning. The 9.2 million excludes the 11 states that run their own exchanges, which have signed up around 3 million additional people.<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 that a person has health insurance, reducing the effectiveness of the individual mandate, in response to an executive order from President Donald Trump.<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=2017-02-16 |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 [[United States House of Representatives]] voted to repeal the ACA using the [[American Health Care Act of 2017]].<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=5 May 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=5 May 2017 |work=WSJ |date=5 May 2017}}</ref> The individual mandate was repealed starting in 2019 via the "Tax Cuts and Jobs Act of 2017".<ref name="hatchsays" /> The CBO estimated that the repeal would cause 13 million people to lose their health insurance by 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 (magazine)|Money]]|date=December 2, 2017|first=Elizabeth|last=O'Brien}}</ref>

By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicare or via an alternative program.<ref name=Advisory.com>{{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>

===Murray—Alexander Individual Market Stabilization Bill===
{{Main|Murray—Alexander Individual Market Stabilization Bill}}
Senator [[Lamar Alexander]] and Senator [[Patty Murray]] reached a compromise to amend the Affordable Care Act 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> President Trump had stopped paying the cost sharing subsidies and the [[Congressional Budget Office]] estimated his action would cost $200 billion, cause insurance sold on the exchange to cost 20% more and cause one million people to lose insurance.<ref>{{Cite news |url=https://www.vox.com/2017/8/15/16153094/voxcare-cbo-trump-obamacare-sabotage-premiums |title=CBO says Trump's Obamacare sabotage would cost $194 billion, drive up premiums 20% |work=Vox|access-date=2017-10-17}}</ref> The proposed legislation will also provide more flexibility for state waivers, allow a new "Copper Plan" or catastrophic coverage for all, allow interstate insurance compacts, and redirect consumer fees to states for outreach.

==See also==
{{Portal|Government of the United States|Law|Medicine}}
* [[Acronyms in healthcare]]
* [[Community Living Assistance Services and Supports Act]] ("Class Act")
* [[Comparison of the health care systems in Canada and the United States]]
* [[EBSA form 700]]
* [[Health care reform]]
* [[Health systems by country]]
* [[Individual shared responsibility provision]]
* [[King v. Burwell]]
* [[Massachusetts health care reform]] (sometimes called "Romneycare")
* [[Medicaid]]
* [[Medicaid estate recovery]]
* [[Medicare Access and CHIP Reauthorization Act of 2015]] (Reform to the American Health Care system signed into law by President Obama)
* [[National health insurance]]
* [[Single-payer health care]]
* [[Universal health care]]
* [[Universal health coverage by country]]
* U.S. [[health care compared]] with 8 other countries (tabular form)
* [[Florida shuffle]]


==References==
{{reflist|30em|refs=

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<ref name=":10">{{Cite web |url=http://www.cnsnews.com/news/article/medicaid-estimate-renews-cost-concerns-over-obamacare |title=Cost of Obamacare Medicaid Expansion 49% Higher Than Previously Estimated |date=August 12, 2016 |accessdate=August 13, 2016 |archive-url=https://web.archive.org/web/20160813135318/http://www.cnsnews.com/news/article/medicaid-estimate-renews-cost-concerns-over-obamacare |archive-date=August 13, 2016 |dead-url=yes |df=mdy-all }}</ref>

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

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

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

<ref name="CBO-Reid-Dec2009">{{cite web |url=http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-Reid_Letter_Managers_Correction_Noted.pdf |title=Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act |publisher=Congressional Budget Office |date=December 19, 2009 |accessdate=March 22, 2010}}</ref>

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<ref name=cbouninsured>{{cite web |url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf |title=Cost Estimate for Pending Health Care Legislation |date=March 20, 2010 |publisher=[[Congressional Budget Office]] |accessdate=March 28, 2010}}</ref>

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

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

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

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

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

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

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

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

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

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

<ref name="CNNMedicaid">{{cite news |url=http://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html |title=States forgo billions by opting out of Medicaid expansion |author=Tami Luhby |publisher=CNN |date=July 1, 2013}}</ref>

<ref name="CohnOE">{{cite news |url=https://newrepublic.com/article/114163/limited-enrollment-periods-obamacare-means-young-people-cant-wait |title=Burn Your Obamacare Card, Burn Yourself |last=Cohn |first=Jonathan |date=August 5, 2013 |work=The New Republic}}</ref>

<ref name=cohnman>{{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>

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

<ref name="CohnInsuranceStandards">{{cite news |url=https://newrepublic.com/article/113440/obamacare-rate-shock-higher-prices-can-mean-better-benefits |title=You Call This Insurance? |last=Cohn |first=Jonathan |date=June 12, 2013 |work=The New Republic}}</ref>

<ref name=CommonSense>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |work=The New Republic |date=April 9, 2010}}</ref>

<ref name="Const-Revenue">[[United States Constitution|U.S. Const.]] art. I, § 7, cl. 1.</ref>

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

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

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

<ref name=cwfstate>{{cite web |url=http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jul/State-Health-Insurance-Exchange-Laws.aspx?omnicid=20 |title=State Health Insurance Exchange Laws: The First Generation |date=July 25, 2012 |publisher=The CommonWealth Fund}}</ref>

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

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

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

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

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

<ref name="FamiliesUSABOR">{{cite press release |title=The Patients' Bill of Rights: Ending annual and lifetime limits |date=September 23, 2010 |publisher=FamiliesUSA |url=http://www.familiesusa.org/health-reform-central/september-23/Annual-and-Lifetime-Limits.pdf |accessdate=April 9, 2012 |deadurl=yes |archiveurl=https://web.archive.org/web/20120331052105/http://www.familiesusa.org/health-reform-central/september-23/Annual-and-Lifetime-Limits.pdf |archivedate=March 31, 2012 |df=mdy-all }}</ref>

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

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

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

<ref name="Feb2009JointSessionAddress">{{Cite news |url=http://www.whitehouse.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress |title=Remarks of President Barack Obama – Address to Joint Session of Congress |date=February 24, 2009 |publisher=The White House |accessdate=March 24, 2010 |deadurl=yes |archiveurl=https://web.archive.org/web/20100308180312/http://www.whitehouse.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress |archivedate=March 8, 2010}}</ref>

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

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

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

<!--<ref name="Gallup">{{cite journal |journal=Gallup Polling |title=U.S. Uninsured Rate at 11.0%, Lowest in Eight-Year Trend |first=Stephanie |last=Marken |date=April 7, 2016 |url=http://www.gallup.com/poll/190484/uninsured-rate-lowest-eight-year-trend.aspx}}</ref>-->

<ref name=governorromney>{{cite web |first=Molly |last=Ball |title=Was Mitt Romney a Good Governor? |url=https://www.theatlantic.com/politics/archive/2012/05/was-mitt-romney-a-good-governor/257942 |work=The Atlantic |date=May 31, 2012 |accessdate=October 28, 2013}}</ref>

<ref name=GPO>{{cite web |url=http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleD-chap43-sec4980H.pdf |title=Title 26 – Internal Revenue Code |author=Government Printing Office}}</ref>

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

<ref name="GruberBio2">{{cite web |url=http://economics.mit.edu/faculty/gruberj |title=Jonathan Gruber (economist) |publisher=MIT Department of Economics |accessdate=September 2, 2013 }}{{cite web |url=http://economics.mit.edu/files/7840 |title=Jonathan Gruber: short biography |publisher=MIT Department of Economics |accessdate=September 2, 2013 |deadurl=yes |archiveurl=https://web.archive.org/web/20130928032016/http://economics.mit.edu/files/7840 |archivedate=September 28, 2013 |df=mdy-all }}</ref>

<ref name="GruberMandate">{{cite web |url=http://www.americanprogress.org/issues/2011/02/pdf/gruber_mandate.pdf |title=Health Care Reform without the Individual Mandate |date=February 2011 |publisher=Center for American Progress |author=Jonathan Gruber (economist) |access-date=July 26, 2013 |archive-url=https://web.archive.org/web/20130922165512/http://www.americanprogress.org/issues/2011/02/pdf/gruber_mandate.pdf |archive-date=September 22, 2013 |dead-url=yes |df=mdy-all }}</ref>

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

<ref name="healthcare">{{cite web |url=http://www.healthcare.gov/law/about/order/byyear.html |title=Provisions of the Affordable Care Act, By Year |publisher=HealthCare.gov |accessdate=January 9, 2012 |deadurl=yes |archiveurl=https://web.archive.org/web/20110909133159/http://www.healthcare.gov/law/about/order/byyear.html |archivedate=September 9, 2011 |df=mdy-all }}</ref>

<ref name=hcgess>{{cite web |url=https://www.healthcare.gov/glossary/essential-health-benefits |title=Essential Health Benefits |publisher=HealthCare.gov, managed by the [[Centers for Medicare and Medicaid Services]]}}<br />
{{cite web |url=https://www.healthcare.gov/what-does-marketplace-health-insurance-cover |title=What does Marketplace health insurance cover? |publisher=HealthCare.Gov, managed by the [[Centers for Medicare and Medicaid Services]]}}</ref>

<ref name="HealthCare Reform Magazine">{{cite web |url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and MedicaidExpansion |work=HealthCare Reform Magazine |date=July 13, 2010 |accessdate=January 9, 2012}}</ref>

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

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

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

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

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

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

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

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

<ref name=jic>{{cite news |url=https://newrepublic.com/blog/plank/103875/obamacare-supreme-court-mandate-contingency-survive |title=Just in Case: How Reform Might Survive Without the Mandate |last=Cohn |first=Jonathan |date=June 8, 2012 |work=The New Republic}}</ref>

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

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

<ref name=KaiserMedicaid>{{cite web |title=Status of State Action on the Medicaid Expansion Decision, as of September 1, 2015 |url=https://www.kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/ |publisher=Kaiser Family Foundation |date=June 22, 2015}}</ref>

<ref name="KaiserFamily">{{cite web |url=http://kff.org/health-costs/issue-brief/explaining-health-care-reform-questions-about-health/ |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |date=July 1, 2012 |publisher=Kaiser Family Foundation |accessdate=July 1, 2012}}</ref>

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

<ref name="KaiserSummary">{{cite news |url=http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf |title=Summary of the Affordable Care Act |date=April 23, 2013 |publisher=Kaiser Family Foundation |deadurl=yes |archiveurl=https://web.archive.org/web/20131003011827/http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf |archivedate=October 3, 2013 |df=mdy-all }}</ref>

<ref name="KFF1">{{cite web |url=http://kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip |title=Where are States Today? Medicaid and CHIP Eligibility Levels for Children and Non-Disabled Adults |date=March 28, 2013 |publisher=Kaiser Family Foundation}}</ref>

<ref name=kffpay>{{cite web |url=http://kff.org/health-costs/issue-brief/explaining-health-care-reform-what-is-an/ |title=Explaining Health Care Reform: What is Employer "Pay-or-Play" Requirement? |date=May 1, 2009 |publisher=[[Kaiser Family Foundation]] |accessdate=January 9, 2012}}</ref>

<ref name=kffpoll>{{cite web |url=http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8451-t.pdf |title=Pg 14 of 'Kaiser Health Tracking Poll: June 2013{{'-}}|date=June 2013|publisher=Kaiser Family Foundation}}</ref>

<ref name=kffunin>{{cite web |url=http://kff.org/state-category/health-coverage-uninsured |title=Health Coverage & Uninsured |date=June 20, 2013 |publisher=Kaiser Family Foundation}}<br />
{{cite web |url=http://kff.org/other/state-indicator/total-population |title=Health Insurance Coverage of the Total Population |date=June 20, 2013 |publisher=Kaiser Family Foundation}}</ref>

<ref name="ksr_hlth">{{cite news |url=http://www.kaiserhealthnews.org/Stories/2010/March/22/consumers-guide-health-reform.aspx |title=Consumers Guide To Health Reform |last=Galewitz |first=Phil |date=March 26, 2010 |publisher=Kaiser Health News}}</ref>

<ref name="Kliff">{{cite news |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/01/five-facts-about-the-health-laws-contraceptive-mandate |title=Five facts about the health law's contraceptive mandate |last=Kliff |first=Sarah |date=August 1, 2012 |newspaper=The Washington Post |accessdate=November 29, 2012}}</ref>

<ref name="Kliff, Sarah">{{cite news |url=https://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |work=The Washington Post |accessdate=July 15, 2012}}</ref>

<ref name=KliffPartTime>{{cite news |title=Will Obamacare lead to millions more part-time workers? Companies are still deciding |author=Sarah Kliff |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/06/will-obamacare-lead-to-millions-more-part-time-workers-companies-are-still-deciding |newspaper=The Washington Post |date=May 6, 2013}}</ref>

<ref name="LimitedOEForbes">{{cite news |url=https://www.forbes.com/sites/carolynmcclanahan/2013/08/04/readers-questions-about-obamacare-misinformation-abounds |title=Reader's Questions About Obamacare – Misinformation Abounds |last=McClanahan |first=Carolyn |date=August 4, 2013 |newspaper=Forbes |accessdate=August 15, 2013}}</ref>

<ref name=man1>{{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}}</ref>

<ref name=man2>{{cite web |url=http://www.slideshare.net/cbo/effects-of-eliminating-the-individual-mandate-to-obtain-health-insurance |title=Effects of Eliminating the Individual Mandate to Obtain Health Insurance |last=Banthin |first=Jessica |date=March 20, 2012 |publisher=CBO}}</ref>

<ref name="Mandate3">{{cite news |url=https://newrepublic.com/article/113851/obamacare-individual-mandate-republicans-push-delay |title=Obamacare's Individual Mandate Can't Wait |last=Cohn |first=Jonathan |date=July 15, 2013 |work=The New Republic}}</ref>

<ref name="MandateRepeal">{{cite news |title=Will Obamacare lead to millions more part-time workers? Companies are still deciding |author=Ezra Klein |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/07/02/obamacares-employer-mandate-shouldnt-be-delayed-it-should-be-repealed |newspaper=The Washington Post |date=July 2, 2013}}</ref>

<ref name="Medicaiddeal">{{cite web |url=https://www.usnews.com/debate-club/is-medicaid-expansion-good-for-the-states |title=Is Medicaid Expansion Good for the States? |work=U.S. News & World Report |date=n.d.}}</ref>

<ref name=most>{{cite news |last=Zengerle |first=Patricia |url=https://www.reuters.com/article/2012/06/24/us-usa-campaign-healthcare-idUSBRE85N01M20120624 |title=Reuters-Most Americans Oppose Health Law But Like the Provisions |work=Reuters |date=June 24, 2012 |accessdate=June 28, 2012}}</ref>

<ref name="multiple2">PriceWaterHouseCoopers. "The CLASS Act." HRS Insight: Human Resource Services. 2010: 1–6. Web.</ref>

<ref name="naic.org">{{cite web |url=http://www.naic.org/documents/committees_b_Exchanges.pdf |title=Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges |date=April 20, 2010 |publisher=National Association of Insurance Commissioners |accessdate=April 9, 2012}}</ref>

<ref name="newsweek-clinton">{{cite news |first=Bob |last=Cohn |first2=Eleanor |last2=Clift |url=http://www.newsweek.com/lost-chance-188330 |title=The Lost Chance |work=[[Newsweek]] |date=September 18, 1994 |accessdate=July 2, 2012}}</ref>
<ref name="notcovered">{{cite news |url=http://www.csmonitor.com/USA/2010/0323/Obama-signs-health-care-bill-Who-won-t-be-covered |title=Obama signs health care bill: Who won't be covered? |last=Trumbull |first=Mark |date=March 23, 2010 |work=[[The Christian Science Monitor]] |accessdate=March 24, 2010}}</ref>

<ref name="new-yorker-klein">{{cite news |work=[[The New Yorker]] |first=Ezra |last=Klein |authorlink=Ezra Klein |title=Unpopular Mandate |date=June 25, 2012 |url=http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein |accessdate=June 19, 2012}}</ref>

<ref name="new-yorker-lizza">{{cite news |work=[[The New Yorker]] |title=Romney's dilemma |url=http://www.newyorker.com/reporting/2011/06/06/110606fa_fact_lizza |first=Ryan |last=Lizza |authorlink=Ryan Lizza |date=June 6, 2011 |accessdate=June 19, 2012}}</ref>

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<ref name="Not so">{{cite news |title=Sarah Palin falsely claims Barack Obama runs a "death panel" |publisher=[[PolitiFact]] |date=August 10, 2009 |url=http://www.politifact.com/truth-o-meter/statements/2009/aug/10/sarah-palin/sarah-palin-barack-obama-death-panel}}</ref>

<ref name="NPRPartTime">{{cite news |title=As Health Law Changes Loom, A Shift To Part-Time Workers |url=https://www.npr.org/2013/04/29/179864601/as-health-law-changes-loom-a-shift-to-part-time-workers |publisher=NPR |date=April 29, 2013}}</ref>

<ref name="NRCohnNJ">{{cite news |url=https://newrepublic.com/blog/jonathan-cohn/101948/supreme-court-mandate-new-jersey-insurance-reform |title=Reform With No Mandate? Ask New Jersey About That |last=Cohn |first=Jonathan |date=March 21, 2012 |work=The New Republic}}</ref>

<ref name="NYMagChait2">{{cite news |url=http://nymag.com/daily/intelligencer/2013/05/yuval-levin-dissembles-madly.html |title=Yuval Levin Dissembles Madly |last=Chait |first=Jonathan |date=May 29, 2013 |work=New York}}</ref>

<ref name="Nursingworld.org">{{cite web |url=http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Health-Care-Reform-Legislation-Timeline.pdf |title=Selected Patient Protection and Affordable Care Act (PPACA) implementation dates of interest to RNs as caregivers, RNs as patients, and RNs as employees |publisher=Nursingworld.org |accessdate=April 9, 2012 |deadurl=yes |archiveurl=https://web.archive.org/web/20120514010100/http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Health-Care-Reform-Legislation-Timeline.pdf |archivedate=May 14, 2012 |df=mdy-all }}</ref>

<ref name="NYT-20131018">{{cite news |last=Stolberg |first=Sheryl Gay |title=States Are Focus of Effort to Foil Health Care Law |url=https://www.nytimes.com/2013/10/19/us/politics/states-are-focus-of-effort-to-foil-health-care-law.html |date=October 18, 2013 |work=[[The New York Times]] |accessdate=October 19, 2013}}</ref>

<ref name="NYT-20140126">{{cite news |author1=The Editorial Board |title=The Koch Party |url=https://www.nytimes.com/2014/01/26/opinion/sunday/the-koch-party.html |date=January 25, 2014 |work=[[The New York Times]] |accessdate=January 25, 2014}}</ref>

<ref name="NYT20120803">{{cite news |last=Baker |first=Peter |title=Democrats Embrace Once Pejorative 'Obamacare' Tag |url=https://www.nytimes.com/2012/08/04/health/policy/democrats-embrace-once-pejorative-obamacare-tag.html?_r=1 |newspaper=The New York Times |date=August 3, 2012 |accessdate=August 6, 2012}}</ref>

<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>

<!-- remmed out
<ref name="NYT-20131231">{{cite news |last=Moore |first=Michael |authorlink=Michael Moore |title=The Obamacare We Deserve |url=https://www.nytimes.com/2014/01/01/opinion/moore-the-obamacare-we-deserve.html |date=December 31, 2013 |work=[[The New York Times]] |accessdate=January 6, 2014}}</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>

<ref name=NYT80213>{{cite news |title=Missouri Citizens Face Obstacles to Coverage |url=https://www.nytimes.com/2013/08/03/us/missouri-citizens-face-obstacles-to-coverage.html |newspaper=The New York Times |date=August 2, 2013 |first=Robert |last=Pear |accessdate=August 3, 2013}}</ref>

<ref name="nytimesjourney">{{Cite news |title=Health Vote Caps a Journey Back From the Brink |first=Sheryl |last=Stolberg |first2=Jeff |last2=Zeleny |first3=Carl |last3=Hulse |url=https://www.nytimes.com/2010/03/21/health/policy/21reconstruct.html |newspaper=[[The New York Times]] |date=March 20, 2010 |accessdate=March 23, 2010}}</ref>

<ref name="nyt-mandate">{{cite news |work=[[The New York Times]] |title=Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later |first=Michael |last=Cooper |date=February 14, 2012 |url=https://www.nytimes.com/2012/02/15/health/policy/health-care-mandate-was-first-backed-by-conservatives.html |accessdate=July 2, 2012}}</ref>

<ref name="NYTLowrey1">{{Cite journal |first=Annie |last=Lowrey |date=May 7, 2013 |url=https://www.nytimes.com/2013/05/07/business/slowdown-in-rise-of-health-care-costs-may-persist.html |title=Slowdown in Rise of Healthcare Costs May Persist |journal=[[The New York Times]] |accessdate=June 10, 2013}}</ref>

<ref name="ObamaPromise">{{cite web |first=Louis |last=Jacobson |title=Barack Obama says that what he'd said was you could keep your plan 'if it hasn't changed since the law passed{{'-}}|url=http://www.politifact.com/truth-o-meter/statements/2013/nov/06/barack-obama/barack-obama-says-what-hed-said-was-you-could-keep/|publisher=PolitiFact |accessdate=November 9, 2013}}</ref>

<ref name=optout>{{cite news |url=http://money.cnn.com/2012/07/23/news/economy/health-reform |title=6 million will lose out on Medicaid expansion |first=Emily Jane |last=Fox |publisher=CNNMoney |date=July 24, 2012 |accessdate=July 25, 2012}}</ref>

<ref name=Ornstein>{{cite news |first=Norm |last=Ornstein |title=The Unprecedented and Contemptible Attempts to Sabotage Obamacare |url=http://www.nationaljournal.com/columns/washington-inside-out/the-unprecedented-and-contemptible-attempts-to-sabotage-obamacare-20130724 |work=National Journal |date=July 24, 2013}}</ref>

<!--<ref name="overhaul">{{cite news |url=https://www.reuters.com/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628 |title=US top court upholds healthcare law in Obama triumph |work=Reuters |first=James |last=Vicini |first2=Jonathan |last2=Stempel |date=June 28, 2012}}</ref>-->

<ref name="paulryan">{{cite news |title=The Facts Are In and Paul Ryan Is Wrong |first=Jonathan |last=Chait |work=New York |date=May 10, 2013 |url=http://nymag.com/daily/intelligencer/2013/05/facts-are-in-and-paul-ryan-is-wrong.html}}</ref>

<ref name="PelosiSawyer">{{Cite news |title=Pelosi Defends Health Care Fight Tactics |first=Margaret |last=Aro |first2=Mark |last2=Mooney |url=http://abcnews.go.com/WN/Politics/house-speaker-nancy-pelosis-exclusive-interview-diane-sawyer/story?id=10172685 |newspaper=[[ABC News]] |date=March 22, 2010 |accessdate=March 23, 2010}}</ref>

<ref name="politifact1993">{{cite web |url=http://www.politifact.com/truth-o-meter/statements/2012/apr/19/facebook-posts/facebook-post-says-republicans-embraced-individual |title=Facebook post says Republicans embraced individual mandate in 1993 |publisher=PolitiFact |date=April 19, 2012}}</ref>

<ref name="PoliticoPelosi">{{Cite news |title=Pelosi steeled W.H. for health push |first=Carrie |last=Brown |first2=Glenn |last2=Thrush |url=http://www.politico.com/news/stories/0310/34753.html |newspaper=[[Politico]] |date=March 20, 2010 |accessdate=March 23, 2010}}</ref>

<ref name="Pool">{{cite web |url=http://www.lifehealthpro.com/2010/10/07/after-ppaca-the-future-of-the-health-insurance-und |title=After PPACA: The Future of the Health Insurance Underwriter |last=Pool |first=Gentrie |date=October 7, 2010 |publisher=Asjonline.com |accessdate=April 9, 2012 |archive-url=https://web.archive.org/web/20120403103904/http://www.lifehealthpro.com/2010/10/07/after-ppaca-the-future-of-the-health-insurance-und |archive-date=April 3, 2012 |dead-url=yes |df=mdy-all }}</ref>

<!--<ref name=PPACA2010>{{cite web |title=Public Law 111–148 |publisher=[[United States Government Printing Office]] |location=Washington, D.C. |date=March 23, 2010 |url=http://www.gpo.gov/fdsys/granule/PLAW-111publ148/PLAW-111publ148/content-detail.html |accessdate=December 22, 2013}}</ref>-->

<ref name="promise">{{cite web |first=Andrew |last=Cline |title=How Obama Broke His Promise on Individual Mandates |url=https://www.theatlantic.com/politics/archive/2012/06/how-obama-broke-his-promise-on-individual-mandates/259183/ |work=The Atlantic |accessdate=September 26, 2013}}</ref>

<ref name=PublicOption>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/the-public-option-still-dead |title=The Public Option, Still Dead |work=The New Republic |date=March 12, 2010}}</ref>

<ref name=randaff>{{cite web |url=https://www.rand.org/content/dam/rand/pubs/technical_reports/2012/RAND_TR1221.pdf |title=The Effect of the Affordable Care Act on Enrollment and Premiums, With and Without the Individual Mandate |last=Eibner |first=Christine |last2=Price |first2=Carter |year=2012 |publisher=Rand Health}}</ref>

<ref name="rcp">{{cite web |url=http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls |title=Obama and Democrats' Health Care Plan |publisher=RealClearPolitics |date=October 13, 2013 |accessdate=March 26, 2014}}</ref>

<ref name="Reconciliationprimer">{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/brief-reconciliation-primer |title=A Brief Reconciliation Primer |work=The New Republic |date=February 20, 2010}}</ref>

<ref name="ReferenceB">{{cite web |url=http://www.shrm.org/publications/hrnews/pages/coverpreventivecare.aspx |title=Login |accessdate=February 18, 2015}}</ref>

<ref name="ReformWithoutTheMandate">{{cite news |url=https://newrepublic.com/blog/the-study/102118/health-care-reform-without-the-mandate |title=Health Care Reform Without The Mandate? |last=Pippenger |first=Nathan |date=March 28, 2012 |work=The New Republic}}</ref>

<ref name="REG-138006-12">{{cite journal |last=Madara |first=Matthew R. |date=February 11, 2014 |title=ACA Employer Shared Responsibility Delay Included in Final Regs |journal=Tax Notes Today |volume=2014 TNT 28–1}}</ref>

<ref name="reuterstimeline">{{cite news |url=https://www.reuters.com/article/idUSTRE62L0JA20100322 |work=Reuters |title=Timeline: Milestones in Obama's quest for healthcare reform |date=March 22, 2010 |accessdate=March 22, 2010}}</ref>

<ref name="RollCallCBO">{{Cite news |title=CBO: Health Care Overhaul Would Cost $940&nbsp;Billion |first=Steven |last=Dennis |url=http://www.rollcall.com/news/44347-1.html |newspaper=[[Roll Call]] |date=March 18, 2010 |accessdate=March 22, 2010}}</ref>

<ref name="salon08132013">{{cite news |first=Brian |last=Beutler |title=A new kind of birther and death panel insanity explodes |url=http://www.salon.com/2013/08/13/republicans_still_pander_to_birthers_and_death_panelists/ |work=Salon |date=August 13, 2013 |accessdate=December 3, 2013}}</ref>

<ref name="sec1401">{{Cite web|url=https://en.wikisource.org/wiki/Patient_Protection_and_Affordable_Care_Act/Title_I/Subtitle_E/Part_I/Subpart_A|title=Patient Protection and Affordable Care Act|first=United States|last=Congress|via=Wikisource}}</ref>

<ref name="sec1401_p">[[s:Patient Protection and Affordable Care Act/Title I/Subtitle E/Part I/Subpart A#appl pct|Patient Protection and Affordable Care Act: Title I: Subtitle E: Part I: Subpart A: Premium Calculation]]</ref>

<ref name="S.334summary">{{cite web |title=Bill Summary & Status – S.334 |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d110:SN00334:@@@S |publisher=[[Library of Congress]] [[THOMAS]] |accessdate=September 24, 2013}}</ref>

<ref name="SchiffHardinLLP">{{cite web |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |title=Next Steps to Comply with Health Care Reform |date=October 10, 2012 |work=The National Law Review |accessdate=October 10, 2012}}</ref>

<ref name="Sep2008FirstPresidentialDebate">{{Cite news |url=http://elections.nytimes.com/2008/president/debates/transcripts/first-presidential-debate.html |title=The First Presidential Debate |date=September 26, 2008 |work=The New York Times}}</ref>

<ref name="Sep2009JointAddress">{{cite web |url=http://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care |title=Remarks by the President to a Joint Session of Congress on Health Care |date=September 10, 2009 |publisher=The White House |accessdate=March 24, 2010 |deadurl=yes |archiveurl=https://web.archive.org/web/20100308000433/http://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care |archivedate=March 8, 2010}}</ref>

<ref name="ServicemembersHomeOwnershipTaxAct">{{Cite news |url=https://www.congress.gov/bill/111th-congress/house-bill/3590/summary/81 |title=Summary: H.R.3590 — 111th Congress (2009–2010) |publisher=Library of Congress |date=July 30, 2017}}</ref>

<ref name="SHNS">{{cite news |url=http://public.shns.com/node/52359 |title=Health reform bill will cause several near-term changes |last=Bowman |first=Lee |date=March 22, 2010 |agency=Scripps Howard News Service |accessdate=March 23, 2010 |deadurl=yes |archiveurl=https://web.archive.org/web/20101227022643/http://public.shns.com/node/52359 |archivedate=December 27, 2010 |df=mdy-all }}</ref>

<ref name="snopes1">{{cite web |url=http://snopes.com/politics/medical/euthanasia.asp |title=Euthanasia Counseling |publisher=Snopes |date=August 13, 2009}}</ref>

<ref name="StateWaiverConditions">{{cite web |url=http://www.healthcare.gov/news/factsheets/stateinnovation03102011a.html |title=Preparing for Innovation: Proposed Process for States to Adopt Innovative Strategies to Meet the Goals of the Affordable Care Act |date=November 16, 2011 |publisher=U.S. Department of Health & Human Services |accessdate=April 1, 2012}}</ref>

<ref name="swanson">{{cite news |url=http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html |work=Pollster.com |first=Emily |last=Swanson |title=Health Care Plan: Favor/Oppose |date=July 30, 2009}}</ref>

<ref name="TamiLuhby">{{cite news |url=http://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html |title=Millions eligible for Obamacare subsidies, but most don't know it |last=Luhby |first=Tami |date=April 23, 2013 |publisher=[[CNNMoney]] |accessdate=June 22, 2013}}</ref>

<ref name="thehill">{{cite web |last=Strauss |first=Daniel |title=Obama camp's pitch to supporters: 'Hell yeah, I'm for Obamacare{{'-}}|work=[[The Hill (newspaper)|The Hill]]|date=March 23, 2012|url=http://thehill.com/blogs/blog-briefing-room/news/217893-obama-reelection-campaign-urges-supporters-to-say-im-for-obamacare|accessdate=March 27, 2012}}</ref>

<ref name="Top 18">{{cite news |url=http://www.huffingtonpost.com/2010/03/22/the-top-18-immediate-effe_n_508315.html#s75147 |title=The Top 18 Immediate Effects Of The Health Care Bill |last=Binckes |first=Jeremy |date=March 22, 2010 |work=The Huffington Post |last2=Wing |first2=Nick |accessdate=March 22, 2010}}</ref>

<!-- remmed out
<ref name="TNR-20140105">{{cite news |author=Noam Schieber |title=How Obamacare Actually Paves the Way Toward Single Payer |url=https://newrepublic.com/article/116105/obamacare-will-lead-single-payer-michael-moore |date=January 5, 2014 |work=[[The New Republic]] |accessdate=January 7, 2014}}</ref>
-->

<ref name="thirtyone">{{cite news |url=http://articles.baltimoresun.com/2012-07-11/health/bal-republicans-repeal-health-reform_1_house-votes-repeal-care-reform-bill |title=House of representatives votes to repeal health reform for the 31st time |last1=Walker |first1=Andrea K. |work=The Baltimore Sun |date=July 11, 2012 |accessdate=July 12, 2012}}</ref>

<ref name="thirtythree">{{cite news |url=http://abcnews.go.com/blogs/politics/2012/07/house-obamacare-repeal-thirty-third-times-the-charm |publisher=ABC News |title=House Obamacare Repeal: Thirty-Third Time's the Charm? |date=July 11, 2012}}</ref>

<ref name="treasurystatement">{{cite web |url=http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx |title=Continuing to Implement the ACA in a Careful, Thoughtful Manner |last=Mazur |first=Mark |publisher=United States Department of the Treasury |accessdate=July 16, 2013}}</ref>

<!--<ref name=uspl111148>{{USPL|111|148}}, {{USStat|124|119}}</ref>-->

<ref name="USH RC 2010-165">{{cite web |url=http://clerk.house.gov/evs/2010/roll165.xml |title=Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act) |publisher=Office of the Clerk: House of Representatives |date=March 21, 2010 |accessdate=April 9, 2012}}</ref>

<ref name="USS RC 2009-396">{{cite web |url=https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396 |title=Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended) |publisher=[[United States Senate|U.S. Senate]] |accessdate=January 9, 2012}}</ref>

<ref name="VermontGMC1">{{cite web |url=http://governor.vermont.gov/http%3A/%252Fgovernor.vermont.gov/node/add/media-federal-rules |title=Gov. Shumlin issued the following statement on health care rules |date=March 14, 2011 |publisher=Governor.vermont.gov |accessdate=April 1, 2012 |deadurl=yes |archiveurl=https://web.archive.org/web/20130516084059/http://governor.vermont.gov/http%3A/%252Fgovernor.vermont.gov/node/add/media-federal-rules |archivedate=May 16, 2013 |df=mdy-all }}</ref>

<ref name="VermontGMC2">{{cite web |url=http://www.theatlanticwire.com/national/2011/05/vermont-becomes-first-state-pass-single-payer-health-care/38207 |title=Vermont Becomes First State to Enact Single-Payer Health Care |last=Estes |first=Adam Clark |date=May 26, 2011 |work=The Atlantic |accessdate=April 1, 2012}}</ref>

<ref name="VermontGMC3">{{cite news |url=http://www.huffingtonpost.com/2011/05/26/vermont-health-care-reform-law-single-payer_n_867573.html |title=Vermont Single-Payer Health Care Law Signed By Governor |last=Wing |first=Nicholas |date=May 26, 2011 |work=The Huffington Post}}</ref>

<ref name=wapo>{{cite news |url=https://apps.washingtonpost.com/g/page/politics/labor-leaders-letter-to-harry-reid-and-nancy-pelosi/785/ |title=Labor leaders' letter to Harry Reid and Nancy Pelosi |newspaper=The Washington Post |date=January 27, 2014 |accessdate=February 13, 2014}}</ref>

<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=[[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 |authorlink=Steven Brill (journalist) |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 |authorlink1=Sherry Glied |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=2019-08-20 }}
* {{cite web |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 |work=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 |deadurl=yes |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 |df=mdy-all }}
* {{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=Aug 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)|last=|first=|date=|website=|publisher=|url=https://web.archive.org/web/20110429193146/http://www.healthinsuranceinfo.net/guides_map.htm#altList|archive-url=|archive-date=|dead-url=|access-date=Apr 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&nbsp;– 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==
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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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