Las principales disposiciones de la ACA entraron en vigor en 2014. Para 2016, la proporción de la población sin seguro se había reducido aproximadamente a la mitad, y se estima que había entre 20 y 24 millones de personas cubiertas más. [5] [6] La ley también promulgó una serie de reformas al sistema de prestación de servicios destinadas a limitar los costos de la atención médica y mejorar la calidad. Después de su entrada en vigor, los aumentos del gasto general en atención médica se desaceleraron, incluidas las primas de los planes de seguro basados en el empleador. [7]
El aumento de la cobertura se debió, en términos más o menos iguales, a una ampliación de la elegibilidad para Medicaid y a cambios en los mercados de seguros individuales . Ambos recibieron nuevos gastos, financiados mediante una combinación de nuevos impuestos y recortes a las tarifas de los proveedores de Medicare y Medicare Advantage . Varios informes de la Oficina de Presupuesto del Congreso (CBO) dijeron que, en general, estas disposiciones redujeron el déficit presupuestario , que la derogación de la ACA aumentaría el déficit, [8] [9] y que la ley redujo la desigualdad de ingresos al gravar principalmente al 1% más rico para financiar aproximadamente $600 en beneficios en promedio para las familias en el 40% más bajo de la distribución de ingresos. [10]
La ley conservó en gran medida la estructura existente de Medicare, Medicaid y el mercado de empleadores , pero los mercados individuales fueron revisados radicalmente. [1] [11] Se obligó a las aseguradoras a aceptar a todos los solicitantes sin cobrarles por condiciones preexistentes o estatus demográfico (excepto la edad). Para combatir la selección adversa resultante , la ley ordenó que las personas compraran un seguro (o pagaran una multa monetaria) y que las aseguradoras cubrieran una lista de " beneficios de salud esenciales ".
Antes y después de su promulgación, la ACA enfrentó una fuerte oposición política, llamados a su derogación y desafíos legales . En el caso de la Federación Nacional de Empresas Independientes contra Sebelius , la Corte Suprema dictaminó que los estados podían optar por no participar en la expansión de Medicaid de la ley, pero confirmó la ley en su conjunto. [12] El intercambio federal de seguros de salud, HealthCare.gov , enfrentó importantes problemas técnicos al comienzo de su implementación en 2013. Las encuestas inicialmente encontraron que una pluralidad de estadounidenses se oponían a la ley, aunque sus disposiciones individuales eran generalmente más populares. [13] Para 2017, la ley tenía un apoyo mayoritario. [14] La Ley de Empleos y Reducción de Impuestos de 2017 fijó la multa por mandato individual en $0 a partir de 2019. [15] Esto planteó dudas sobre si la ACA seguía siendo constitucional. [16] [17] [18] En junio de 2021, la Corte Suprema confirmó la ACA por tercera vez en California contra Texas . [19]
Provisiones
El Presidente y el personal de la Casa Blanca reaccionan ante la aprobación del proyecto de ley por parte de la Cámara de Representantes el 21 de marzo de 2010.Jim Clyburn y Nancy Pelosi celebran después de que la Cámara aprobara el proyecto de ley enmendado el 21 de marzo.
La ACA modificó la Ley del Servicio de Salud Pública de 1944 e insertó nuevas disposiciones sobre atención médica asequible en el Título 42 del Código de los Estados Unidos . [1] [2] [3] [20] [4] El mercado de seguros individuales fue revisado radicalmente, y muchas de las regulaciones de la ley se aplicaron específicamente a este mercado, [1] mientras que la estructura de Medicare, Medicaid y el mercado de empleadores se mantuvieron en gran medida. [2] Algunas regulaciones se aplicaron al mercado de empleadores, y la ley también realizó cambios en el sistema de prestación que afectaron a la mayor parte del sistema de atención médica. [2]
Normativa de seguros: pólizas individuales
Todas las nuevas pólizas de seguro médico individual de gastos mayores vendidas a personas y familias enfrentaron nuevos requisitos. [21] Los requisitos entraron en vigor el 1 de enero de 2014 e incluyen:
Los Estados debían garantizar la disponibilidad de seguro para los niños que no tenían cobertura a través de sus familias.
Una tasa comunitaria parcial permite que las primas varíen únicamente según la edad y la ubicación, independientemente de las condiciones preexistentes. Las primas para los solicitantes mayores no pueden ser más del triple de las de los más jóvenes. [23]
Se deben proporcionar prestaciones sanitarias esenciales . La Academia Nacional de Medicina define las "prestaciones sanitarias esenciales" de la ley como "servicios para pacientes ambulatorios; servicios de urgencias; hospitalización; atención de maternidad y neonatos; servicios de salud mental y trastornos por consumo de sustancias, incluido el tratamiento de la salud conductual; medicamentos con receta; servicios y dispositivos de rehabilitación y habilitación; servicios de laboratorio; servicios preventivos y de bienestar y tratamiento de enfermedades crónicas; y servicios pediátricos, incluida la atención bucal y de la vista" [24] [25] y otros [26] calificados como de nivel A o B [27] por el Grupo de Trabajo de Servicios Preventivos de los Estados Unidos . [28] Al determinar las prestaciones esenciales, la ley exigía que las prestaciones estándar ofrecieran al menos lo que ofrece un "plan típico de empleador". [29] Los estados pueden exigir servicios adicionales. [30]
Atención preventiva y exámenes de detección para mujeres. [31] “[T]odo los métodos anticonceptivos , procedimientos de esterilización y educación y asesoramiento para pacientes aprobados por la Administración de Alimentos y Medicamentos para todas las mujeres con capacidad reproductiva”. [32] Este mandato se aplica a todos los empleadores e instituciones educativas, excepto a las organizaciones religiosas. [33] [34] Estas regulaciones se incluyeron en las recomendaciones del Instituto de Medicina . [35] [36]
En 2012, el senador Sheldon Whitehouse creó este resumen para explicar su opinión sobre la ley.
Se prohibieron los topes de cobertura anual y de por vida para los beneficios esenciales. [37] [38] [39]
Las aseguradoras tienen prohibido dar de baja a los asegurados cuando estos se enferman. [40] [41]
Todas las pólizas deben establecer un límite máximo anual de pago de bolsillo (MOOP) para los gastos médicos de una persona o familia (excluidas las primas). Una vez alcanzado el MOOP, la aseguradora debe pagar todos los costos restantes. [42]
La ley estableció cuatro niveles de cobertura: bronce, plata, oro y platino. Todas las categorías ofrecen beneficios de salud esenciales. Las categorías varían en su división de primas y costos de bolsillo: los planes bronce tienen las primas mensuales más bajas y los costos de bolsillo más altos, mientras que los planes platino son lo opuesto. [29] [47] Los porcentajes de los costos de atención médica que se espera que los planes cubran a través de las primas (en oposición a los costos de bolsillo) son, en promedio: 60% (bronce), 70% (plata), 80% (oro) y 90% (platino). [48]
Las aseguradoras están obligadas a implementar un proceso de apelaciones para la determinación de cobertura y los reclamos en todos los planes nuevos. [40]
El mandato tenía por objeto aumentar el tamaño y la diversidad de la población asegurada, incluyendo más participantes jóvenes y saludables para ampliar el grupo de riesgos y distribuir los costos. [54]
Entre los grupos que no quedaron sujetos al mandato individual se encuentran:
Inmigrantes ilegales . Se estima que su número asciende a 8 millones, aproximadamente un tercio de los 23 millones previstos, y no tienen derecho a subsidios de seguros ni a Medicaid. [55] [56] Siguen teniendo derecho a servicios de emergencia.
Ciudadanos elegibles para Medicaid que no están inscritos en Medicaid. [57]
Ciudadanos cuya cobertura de seguro costaría más del 8% del ingreso familiar. [57]
Ciudadanos que viven en estados que optan por no ampliar Medicaid y que no califican ni para la cobertura existente de Medicaid ni para la cobertura subsidiada. [58]
La ACA ordenó que se proporcionaran bolsas de seguros de salud para cada estado. Las bolsas están reguladas, son en gran parte mercados en línea, administrados por los gobiernos federales o estatales, donde las personas, las familias y las pequeñas empresas pueden comprar planes de seguro privados. [60] [61] [62] Las bolsas ofrecieron seguros por primera vez en 2014. Algunas bolsas también brindan acceso a Medicaid. [63] [64]
Los estados que establecen sus propias bolsas tienen cierta discreción en cuanto a estándares y precios. [65] [66] Por ejemplo, los estados aprueban planes para la venta y, de ese modo, influyen (a través de negociaciones) en los precios. Pueden imponer requisitos de cobertura adicionales, como el aborto. [67] Alternativamente, los estados pueden hacer que el gobierno federal sea responsable de operar sus bolsas. [65]
Subvenciones a las primas
Las personas cuyos ingresos familiares se encuentran entre el 100% y el 400% del nivel federal de pobreza (FPL) son elegibles para recibir subsidios federales para las primas de las pólizas compradas en un intercambio de ACA, siempre que no sean elegibles para Medicare , Medicaid , el Programa de Seguro Médico para Niños u otras formas de cobertura de salud de asistencia pública, y no tengan acceso a una cobertura asequible (no más del 9,86% de los ingresos para la cobertura del empleado) a través de su propio empleador o el de un miembro de la familia. [68] [69] [70] Los hogares por debajo del nivel federal de pobreza no son elegibles para recibir estos subsidios. Los residentes legales y algunos otros inmigrantes legalmente presentes cuyos ingresos familiares están por debajo del 100% del FPL y no son elegibles para Medicaid son elegibles para subsidios si cumplen con todos los demás requisitos de elegibilidad. [71] [68] Las personas casadas deben presentar impuestos en forma conjunta para recibir subsidios. Los inscritos deben tener ciudadanía estadounidense o prueba de residencia legal para obtener un subsidio.
Los subsidios para un plan de la ACA adquirido en una bolsa de seguros se detienen en el 400% del nivel federal de pobreza (FPL). Según la Fundación Kaiser, esto da como resultado una marcada "discontinuidad del tratamiento" en el 400% del FPL, lo que a veces se denomina el "precipicio de subsidios". [72] Las primas después de los subsidios para el segundo plan de plata de menor costo (SCLSP) justo debajo del precipicio son del 9,86% de los ingresos en 2019. [73]
El monto del subsidio es suficiente para reducir la prima del segundo plan de plata de menor costo (SCLSP, por sus siglas en inglés) en un mercado de seguros a un porcentaje de escala móvil de los ingresos. El porcentaje se basa en el porcentaje del nivel federal de pobreza (FPL, por sus siglas en inglés) del hogar y varía levemente de un año a otro. En 2019, osciló entre el 2,08 % de los ingresos (100 %-133 % FPL) y el 9,86 % de los ingresos (300 %-400 % FPL). [70] El subsidio se puede utilizar para cualquier plan disponible en el mercado de seguros, pero no para planes catastróficos. El subsidio no puede superar la prima del plan adquirido.
(En esta sección, el término "ingreso" se refiere al ingreso bruto ajustado modificado . [68] [76] )
Las pequeñas empresas son elegibles para un crédito fiscal siempre que se inscriban en el Mercado SHOP . [77]
Subsidios para la reducción de costos compartidos
Tal como está redactada, la ACA exigía que las aseguradoras redujeran los copagos y deducibles para los beneficiarios de la ACA que ganaran menos del 250% del FPL. Los beneficiarios de Medicaid no eran elegibles para las reducciones.
Para financiar las reducciones se pagarían a las compañías de seguros los llamados subsidios para la reducción de costos compartidos (CSR, por sus siglas en inglés). Durante 2017, se pagarían aproximadamente 7 mil millones de dólares en subsidios para la CSR, frente a 34 mil millones de dólares destinados a créditos fiscales para primas. [78]
Este último se definió como gasto obligatorio que no requiere una asignación anual del Congreso. Los pagos de RSE no se definieron explícitamente como obligatorios, lo que dio lugar a litigios y disrupciones posteriores. [ Se necesita más explicación ]
Gestión de riesgos
La ACA implementó múltiples enfoques para ayudar a mitigar las perturbaciones que sus numerosos cambios provocaron para las aseguradoras.
Aunque muchas aseguradoras ofrecieron inicialmente planes de intercambio, el programa no se amortizó como estaba previsto, perdiendo hasta 8.300 millones de dólares en 2014 y 2015. Se tuvo que dar autorización para que el DHHS pudiera pagar a las aseguradoras con "ingresos generales del gobierno". [ atribución necesaria ] Sin embargo, la Ley de Asignaciones Consolidadas de 2014 (HR 3547) declaró que ningún fondo "podría utilizarse para pagos de corredores de riesgo". [83] [ atribución necesaria ] dejando al gobierno en una posible situación de incumplimiento de contrato con las aseguradoras que ofrecían planes de salud calificados. [84]
Varias aseguradoras demandaron al gobierno en el Tribunal de Reclamaciones Federales de los Estados Unidos para recuperar los fondos que se cree que se les deben en virtud del programa de Corredores de Riesgo. Si bien varios fueron cerrados sumariamente, en el caso de Moda Health v the United States , Moda Health ganó una sentencia de $214 millones en febrero de 2017. El juez de Reclamaciones Federales Thomas C. Wheeler declaró: "el gobierno hizo una promesa en el programa de corredores de riesgo que aún no ha cumplido. Hoy, el tribunal ordena al gobierno que cumpla esa promesa. Después de todo, decirle [a Moda], 'La broma es para ti. No deberías haber confiado en nosotros', no es digno de nuestro gran gobierno". [85] El caso de Moda Health fue apelado por el gobierno ante el Tribunal de Apelaciones de los Estados Unidos para el Circuito Federal junto con las apelaciones de las otras aseguradoras; aquí, el Circuito Federal revocó el fallo de Moda Health y falló en todos los casos a favor del gobierno, que las asignaciones adicionales que cedían al gobierno para pagar seguían siendo dinero adeudado a las aseguradoras. La Corte Suprema revocó esta decisión en el caso consolidado, Maine Community Health Options v. United States , reafirmando, al igual que el juez Wheeler, que el gobierno tenía la responsabilidad de pagar esos fondos bajo la ACA y que el uso de cláusulas adicionales para liberarse de esos pagos era ilegal. [86]
Reaseguro
El programa de reaseguro temporal tiene por objeto estabilizar las primas reduciendo el incentivo de las aseguradoras a aumentarlas debido a preocupaciones sobre los afiliados de mayor riesgo. El reaseguro se basó en costos retrospectivos en lugar de evaluaciones de riesgo prospectivas. El reaseguro estuvo disponible desde 2014 hasta 2016. [87]
Ajuste de riesgo
El ajuste de riesgos implica transferir fondos de planes con afiliados de menor riesgo a planes con afiliados de mayor riesgo. Su objetivo era alentar a las aseguradoras a competir en función del valor y la eficiencia, en lugar de atraer a afiliados más saludables. De los tres programas de gestión de riesgos, sólo el ajuste de riesgos era permanente. Los planes con bajo riesgo actuarial compensan a los planes con alto riesgo actuarial. [87]
Expansión de Medicaid
ACA revisó y amplió la elegibilidad para Medicaid a partir de 2014. Todos los ciudadanos estadounidenses y residentes legales con ingresos de hasta el 133% de la línea de pobreza calificarían para la cobertura en cualquier estado que participara en el programa Medicaid. Anteriormente, los estados podían establecer varios umbrales más bajos para ciertos grupos y no estaban obligados a cubrir a los adultos sin hijos dependientes. El gobierno federal debía pagar el 100% del aumento del costo en 2014, 2015 y 2016; el 95% en 2017, el 94% en 2018, el 93% en 2019 y el 90% en 2020 y todos los años posteriores. [88] [89] [90] [91] Una "desconsideración de ingresos" del 5% hizo que el límite de elegibilidad de ingresos efectivo para Medicaid fuera el 138% del nivel de pobreza. [92] Sin embargo, la Corte Suprema dictaminó en NFIB v. Sebelius que esta disposición de la ACA era coercitiva y que los estados podían optar por continuar con los niveles de elegibilidad anteriores a la ACA.
Los ingresos por cuenta propia y los salarios de personas solteras que superen los 200.000 dólares anuales están sujetos a un impuesto adicional del 0,9%. El importe límite es de 250.000 dólares para una pareja casada que presenta una declaración conjunta (el límite se aplica a su remuneración total), o de 125.000 dólares para una persona casada que presenta una declaración por separado. [95]
En la legislación complementaria de la ACA, la Ley de Reconciliación de Atención Médica y Educación de 2010 , se aplicó un impuesto adicional del 3,8% a los ingresos no derivados del trabajo, específicamente el menor de los ingresos netos por inversiones y el monto en que los ingresos brutos ajustados exceden los límites de ingresos anteriores. [96]
Impuestos especiales
La ACA incluyó un impuesto especial del 40% (" impuesto Cadillac ") sobre el gasto total en primas de los empleadores que excediera de los montos en dólares especificados (inicialmente $10,200 para la cobertura individual y $27,500 para la cobertura familiar [97] ) indexado a la inflación. Este impuesto estaba originalmente programado para entrar en vigencia en 2018, pero se retrasó hasta 2020 por la Ley de Asignaciones Consolidadas de 2016 y nuevamente hasta 2022. El impuesto especial sobre los planes de salud de alto costo fue derogado por completo como parte de la HR1865 - Ley de Asignaciones Consolidadas Adicionales de 2020.
Se aplicaron impuestos especiales por un total de 3.000 millones de dólares a los importadores y fabricantes de medicamentos de venta con receta. También se aplicó un impuesto especial del 2,3% a los dispositivos médicos y un impuesto especial del 10% a los servicios de bronceado artificial. [98] El impuesto se derogó a finales de 2019. [99]
A partir del 23 de septiembre de 2010, se permitió a los dependientes permanecer en el plan de seguro de sus padres hasta que cumplieran 26 años, incluidos los dependientes que ya no vivían con sus padres, no figuraban como dependientes en la declaración de impuestos de sus padres, ya no eran estudiantes o estaban casados. [102] [103]
Mandato del empleador
Las empresas que emplean a cincuenta o más personas pero no ofrecen seguro médico a sus empleados a tiempo completo deben pagar un impuesto adicional si el gobierno ha subvencionado la atención médica de un empleado a tiempo completo mediante deducciones fiscales u otros medios. Esto se conoce comúnmente como el mandato del empleador. [104] [105] Esta disposición se incluyó para alentar a los empleadores a seguir proporcionando seguros una vez que las bolsas comenzaran a funcionar. [106]
Medicare pasó de un sistema de pago por servicio a pagos agrupados . [108] [109] Se debía realizar un pago único a un hospital y a un grupo de médicos por un episodio definido de atención (como un reemplazo de cadera ) en lugar de pagos separados a proveedores de servicios individuales. [110]
La Ley permitió la creación de organizaciones de atención responsable (ACO), que son grupos de médicos, hospitales y otros proveedores que se comprometen a brindar atención coordinada a los pacientes de Medicare. Se permitió que las ACO siguieran utilizando la facturación por servicio . Reciben pagos adicionales del gobierno por minimizar los costos y al mismo tiempo lograr parámetros de calidad que enfatizan la prevención y mitigación de enfermedades crónicas . El incumplimiento de los parámetros de calidad o costo las exponía a sanciones. [112]
A diferencia de las organizaciones de mantenimiento de la salud , los pacientes de las ACO no están obligados a obtener toda la atención de la ACO. Además, a diferencia de las HMO, las ACO deben alcanzar objetivos de calidad de la atención. [112]
A partir de 2017, los estados pueden solicitar una "exención para la innovación estatal" que les permite realizar experimentos que cumplan ciertos criterios. [115] Para obtener una exención, un estado debe aprobar una legislación que establezca un sistema de salud alternativo que proporcione un seguro al menos tan integral y asequible como el ACA, cubra al menos a la misma cantidad de residentes y no aumente el déficit federal. [116] Estos estados pueden escapar de algunos de los requisitos centrales de la ACA, incluidos los mandatos para individuos y empleadores y la provisión de una bolsa de seguros. [117] El estado recibiría una compensación equivalente al monto agregado de los subsidios federales y créditos fiscales para los que sus residentes y empleadores habrían sido elegibles bajo la ACA, si no pueden ser pagados bajo el plan estatal. [115]
Los planes operados y orientados al consumidor (CO-OP), aseguradoras sin fines de lucro gobernadas por sus miembros, podrían comenzar a brindar cobertura de atención médica, con base en un préstamo federal a cinco años. [122] En 2017, solo cuatro de las 23 cooperativas originales seguían en funcionamiento. [123]
Requisitos de etiquetado nutricional
Los requisitos de etiquetado nutricional entraron en vigor oficialmente en 2010, pero su implementación se retrasó y, en realidad, entraron en vigor el 7 de mayo de 2018. [124]
Historial legislativo
El Presidente Obama firma la Ley de Protección al Paciente y Atención Médica Asequible el 23 de marzo de 2010.
La ACA siguió a una larga serie de intentos infructuosos de uno u otro partido para aprobar reformas importantes en materia de seguros. Las innovaciones se limitaron a las cuentas de ahorro para la salud (2003), las cuentas de ahorro para gastos médicos (1996) o las cuentas de gastos flexibles , que aumentaron las opciones de seguro, pero no ampliaron materialmente la cobertura. La atención médica fue un factor importante en múltiples elecciones, pero hasta 2009, ninguno de los partidos tenía los votos necesarios para superar la oposición del otro.
La Ley de Reforma de Equidad y Acceso a la Salud Republicana de 1993 (HEART, por sus siglas en inglés) contenía un requisito de "cobertura universal" con una penalidad por incumplimiento (un mandato individual), así como subsidios para ser utilizados en "grupos de compra" basados en el estado. [132] Los defensores incluyeron senadores republicanos prominentes como John Chafee , Orrin Hatch , Chuck Grassley , Bob Bennett y Kit Bond . [133] [134] La Ley de Seguridad Sanitaria de Elección del Consumidor Republicana de 1994, inicialmente contenía un mandato individual con una disposición de penalidad; [135] sin embargo, el autor Don Nickles posteriormente eliminó el mandato, declarando que "el gobierno no debería obligar a las personas a comprar un seguro médico". [136] En el momento de estas propuestas, los republicanos no plantearon cuestiones constitucionales; Mark Pauly, quien ayudó a desarrollar una propuesta que incluía un mandato individual para George HW Bush , comentó: "No recuerdo que se haya planteado eso en absoluto. La forma en que fue visto por la Oficina de Presupuesto del Congreso en 1994 fue, efectivamente, como un impuesto". [125]
El Massachusetts de Mitt Romney pasó del 90% de sus residentes asegurados al 98%, la tasa más alta del país. [137]
En 2006, se promulgó un proyecto de ley de expansión de seguros a nivel estatal en Massachusetts. El proyecto de ley contenía tanto un mandato individual como una bolsa de seguros . El gobernador republicano Mitt Romney utilizó un veto puntual sobre algunas disposiciones, y la legislatura demócrata anuló algunos de sus cambios (incluido el mandato). [138] La implementación por parte de Romney del intercambio 'Health Connector' y el mandato individual en Massachusetts fue alabada en un principio por los republicanos. Durante la campaña presidencial de Romney en 2008 , el senador Jim DeMint elogió la capacidad de Romney de "tomar algunas buenas ideas conservadoras, como el seguro médico privado, y aplicarlas a la necesidad de que todos estén asegurados". Romney dijo sobre el mandato individual: "Estoy orgulloso de lo que hemos hecho. Si Massachusetts logra implementarlo, entonces ese será el modelo para la nación". [139]
En 2008, muchos demócratas ya estaban considerando este enfoque como base para la reforma de la atención sanitaria. Los expertos afirmaron que la legislación que finalmente surgió del Congreso en 2009 y 2010 guardaba similitudes con el proyecto de ley de 2007 [132] y que tomaba ideas de las reformas de Massachusetts. [141]
Fundación académica
Una fuerza impulsora detrás de la reforma de salud de Obama fue Peter Orszag , Director de la Oficina de Administración y Presupuesto . [142] Obama llamó a Orszag su "zar de la salud" debido a su conocimiento de la reforma de salud. [143] Orszag había sido anteriormente director de la Oficina de Presupuesto del Congreso , y bajo su liderazgo la agencia se había centrado en utilizar el análisis de costos para crear un enfoque asequible y eficaz para la reforma de la atención médica. Orszag afirmó que la reforma de la atención médica se convirtió en el tema principal de la agenda de Obama porque quería que fuera su legado. [144] Según un artículo de Ryan Lizza en The New Yorker , el núcleo del "presupuesto de Obama es la creencia de Orszag [en]... un gobierno empoderado con investigación sobre los tratamientos médicos más efectivos". Obama apostó "su presidencia en la tesis de Orszag de efectividad comparativa". [145] Las políticas de Orszag fueron influenciadas por un artículo en The Annals of Internal Medicine [146] coescrito por Elliott S. Fisher, David Wennberg y otros. El artículo presentaba pruebas sólidas basadas en la investigación de los coautores de que se estaban realizando numerosos procedimientos, terapias y pruebas con escasa evidencia de su valor médico. Si se pudieran eliminar esos procedimientos y pruebas, sugería esta evidencia, los costos médicos podrían proporcionar los ahorros necesarios para brindar atención médica a la población sin seguro. [147] Después de leer un artículo del New Yorker que utilizaba los "hallazgos de Dartmouth" [148] para comparar dos condados de Texas con enormes variaciones en los costos de Medicare utilizando datos duros, Obama ordenó que todo su personal lo leyera. [149] Más que cualquier otra cosa, los datos de Dartmouth intrigaron a Obama [150] ya que le dieron una justificación académica para reformular la medicina. [151]
El concepto de comparar la efectividad de las opciones de atención médica basándose en datos concretos ("efectividad comparativa" y "medicina basada en evidencia") fue iniciado por John E. Wennberg, fundador de The Dartmouth Institute , cofundador de The Foundation for Informed Medical Decision Making y asesor principal de Health Dialog Inc., una empresa que él y sus investigadores crearon para ayudar a las aseguradoras a implementar los hallazgos de Dartmouth.
Debate sobre la atención sanitaria, 2008-2010
La reforma del sistema de salud fue un tema importante durante las primarias presidenciales demócratas de 2008. A medida que la carrera se reducía, la atención se centró en los planes presentados por los dos candidatos principales, Hillary Clinton y el candidato final, Barack Obama . Cada candidato propuso un plan para cubrir a los aproximadamente 45 millones de estadounidenses que, según se estima, no tienen seguro médico en algún momento cada año. La propuesta de Clinton habría exigido que todos los estadounidenses obtuvieran cobertura (en efecto, un mandato individual), mientras que la propuesta de Obama preveía un subsidio sin mandato. [152] [153]
Durante las elecciones generales , Obama dijo que arreglar el sistema de salud sería una de sus cuatro prioridades principales como presidente. [154] Obama y su oponente, el senador John McCain , propusieron reformas al seguro de salud, aunque sus planes diferían. McCain propuso créditos fiscales para el seguro de salud adquirido en el mercado individual, lo que se estimó que reduciría el número de personas sin seguro en unos 2 millones para 2018. Obama propuso seguros grupales privados y públicos, subsidios basados en los ingresos, protecciones al consumidor y expansiones de Medicaid y SCHIP, lo que se estimó en ese momento que reduciría el número de personas sin seguro en 33,9 millones para 2018 a un costo más alto. [155]
Obama anunció en una sesión conjunta del Congreso en febrero de 2009 su intención de trabajar con el Congreso para elaborar un plan de reforma de la atención sanitaria. [156] [157] En julio, una serie de proyectos de ley fueron aprobados por comités dentro de la Cámara de Representantes . [158] En el lado del Senado, de junio a septiembre, el Comité de Finanzas del Senado celebró una serie de 31 reuniones para desarrollar una propuesta. Este grupo —en particular, los demócratas Max Baucus , Jeff Bingaman y Kent Conrad , junto con los republicanos Mike Enzi , Chuck Grassley y Olympia Snowe— se reunió durante más de 60 horas, y los principios que discutieron, en conjunto con los otros comités, se convirtieron en la base de un proyecto de ley del Senado. [159] [160] [161]
Sin embargo, tras la incorporación de un mandato individual a la propuesta, los republicanos amenazaron con obstruir cualquier proyecto de ley que lo contuviera. [125] El líder de la minoría del Senado, Mitch McConnell , quien encabezó la respuesta republicana, concluyó que los republicanos no deberían apoyar el proyecto de ley. [166]
Los senadores republicanos, incluidos aquellos que habían apoyado propuestas anteriores con un mandato similar, comenzaron a calificar el mandato de "inconstitucional". El periodista Ezra Klein escribió en The New Yorker : "una política que alguna vez gozó de un amplio apoyo dentro del Partido Republicano de repente se enfrentó a una oposición unificada". [129]
La reforma atrajo la atención de los grupos de presión , [167] incluidos acuerdos entre grupos de presión y defensores para ganar el apoyo de grupos que se habían opuesto a propuestas anteriores. [168] [169] [170]
Durante el receso de verano de agosto de 2009, muchos miembros del Congreso regresaron a sus distritos y celebraron reuniones municipales sobre las propuestas. El naciente movimiento Tea Party organizó protestas y muchos grupos e individuos conservadores asistieron a las reuniones para oponerse a las reformas propuestas. [157] Durante el debate se profirieron amenazas contra miembros del Congreso. [171]
El Senado comenzó a trabajar en sus propias propuestas mientras la Cámara todavía estaba trabajando. La Constitución de los Estados Unidos requiere que todos los proyectos de ley relacionados con los ingresos se originen en la Cámara. [173] Para cumplir formalmente con este requisito, el Senado reutilizó HR 3590, un proyecto de ley sobre cambios en el impuesto a la vivienda para los miembros del servicio. [174] Había sido aprobado por la Cámara como una modificación relacionada con los ingresos al Código de Rentas Internas . El proyecto de ley se convirtió en el vehículo del Senado para su propuesta de reforma de la atención médica, descartando el contenido original del proyecto de ley. [175] El proyecto de ley finalmente incorporó elementos de propuestas que fueron informadas favorablemente por los comités de Salud y Finanzas del Senado . Con la minoría republicana del Senado prometiendo obstruccionismo , se necesitarían 60 votos para aprobar el Senado. [176] Al comienzo del 111.º Congreso , los demócratas tenían 58 votos. Las elecciones al Senado de Minnesota finalmente fueron ganadas por el demócrata Al Franken , con 59 escaños. Arlen Specter se pasó al Partido Demócrata en abril de 2009, lo que les dio 60 escaños, suficientes para poner fin a una obstrucción.
Se llevaron a cabo negociaciones intentando satisfacer a los demócratas moderados y atraer a los senadores republicanos; se prestó especial atención a los republicanos Bennett, Enzi, Grassley y Snowe.
Después de la votación del Comité de Finanzas el 15 de octubre, las negociaciones se dirigieron hacia los demócratas moderados. El líder de la mayoría del Senado, Harry Reid, se centró en satisfacer a los centristas. Los que se resistieron se redujeron a Joe Lieberman de Connecticut, un independiente que se unió a los demócratas, y el demócrata conservador de Nebraska, Ben Nelson . La demanda de Lieberman de que el proyecto de ley no incluyera una opción pública [163] [177] se cumplió, [178] aunque los partidarios obtuvieron varias concesiones, incluida la autorización de opciones públicas basadas en los estados, como el fallido Green Mountain Care de Vermont . [178] [179]
Votación del Senado por estado
Sí demócrata (58)
Independiente si (2)
Republicano no (39)
Republicano no vota (1)
La Casa Blanca y Reid abordaron las preocupaciones de Nelson [180] durante una negociación de 13 horas con dos concesiones: un compromiso sobre el aborto , modificando el lenguaje del proyecto de ley "para dar a los estados el derecho de prohibir la cobertura del aborto dentro de sus propios intercambios de seguros", lo que requeriría que los consumidores paguen el procedimiento de su bolsillo si el estado así lo decide; y una enmienda para ofrecer una tasa más alta de reembolso de Medicaid para Nebraska. [157] [181] La segunda mitad del compromiso fue denominada despectivamente "Cornhusker Kickback" [182] y luego fue eliminada.
El 23 de diciembre, el Senado votó 60-39 para poner fin al debate sobre el proyecto de ley: una votación de clausura para poner fin al obstruccionismo . [183] El proyecto de ley luego fue aprobado, también por 60-39, el 24 de diciembre de 2009, con todos los demócratas y dos independientes votando a favor, y todos los republicanos en contra (excepto Jim Bunning , que no votó). [184] El proyecto de ley fue respaldado por la Asociación Médica Estadounidense y AARP . [185]
El 19 de enero de 2010, el republicano de Massachusetts Scott Brown fue elegido para el Senado en una elección especial para reemplazar al recientemente fallecido Ted Kennedy , después de haber hecho campaña para darle a la minoría republicana el 41.º voto necesario para sostener las maniobras obstruccionistas republicanas. [157] [186] [187] Además, la importancia simbólica de perder el escaño tradicionalmente demócrata de Kennedy en Massachusetts hizo que muchos demócratas del Congreso se preocuparan por el costo político del proyecto de ley. [188] [189]
Obama siguió insistiendo en una reforma integral. La noticia de que Anthem , en California, tenía la intención de aumentar las primas para sus pacientes hasta en un 39% le dio una nueva evidencia de la necesidad de una reforma. [190] [191] El 22 de febrero, presentó una propuesta "con tendencia al Senado" para consolidar los proyectos de ley. [192] Se reunió con los líderes de ambos partidos el 25 de febrero. Los demócratas decidieron que la Cámara aprobaría el proyecto de ley del Senado, para evitar otra votación en el Senado.
Los demócratas de la Cámara de Representantes esperaban poder negociar cambios en una conferencia entre la Cámara y el Senado antes de aprobar un proyecto de ley final. Dado que cualquier proyecto de ley que surgiera de la conferencia que difiriera del proyecto de ley del Senado tendría que aprobarse en el Senado mediante otro filibustero republicano, la mayoría de los demócratas de la Cámara de Representantes acordaron aprobar el proyecto de ley del Senado con la condición de que fuera enmendado por un proyecto de ley posterior. [189] Redactaron la Ley de Reconciliación de la Atención Sanitaria y la Educación , que podría aprobarse mediante el proceso de reconciliación . [190] [193] [194]
Según la Ley de Presupuesto del Congreso de 1974 , la conciliación no puede ser objeto de una maniobra obstruccionista . Pero la conciliación se limita a los cambios presupuestarios , por lo que el procedimiento no se utilizó para aprobar la ACA en primer lugar; el proyecto de ley tenía regulaciones inherentemente no presupuestarias. [195] [196] Aunque el proyecto de ley del Senado ya aprobado no podría haber sido aprobado por conciliación, la mayoría de las demandas de los demócratas de la Cámara de Representantes eran presupuestarias: "estos cambios (niveles de subsidios más altos, diferentes tipos de impuestos para pagarlos, eliminar el acuerdo de Medicaid de Nebraska) involucran principalmente impuestos y gastos. En otras palabras, son exactamente el tipo de políticas que son adecuadas para la conciliación". [193]
El obstáculo restante era un grupo fundamental de demócratas pro-vida liderados por Bart Stupak que inicialmente se mostraron reacios a apoyar el proyecto de ley. El grupo encontró que la posibilidad de financiación federal para el aborto era lo suficientemente significativa como para justificar la oposición. El proyecto de ley del Senado no había incluido un lenguaje que satisficiera sus preocupaciones, pero no podían abordar el aborto en el proyecto de ley de reconciliación, ya que no sería presupuestario. En cambio, Obama emitió la Orden Ejecutiva 13535 , reafirmando los principios de la Enmienda Hyde . [197] Esto ganó el apoyo de Stupak y los miembros de su grupo y aseguró la aprobación del proyecto de ley. [194] [198] La Cámara aprobó el proyecto de ley del Senado con una votación de 219 a 212 el 21 de marzo de 2010, con 34 demócratas y los 178 republicanos votando en contra. [199] Aprobó el segundo proyecto de ley , por 220 a 211, el mismo día (con el Senado aprobando este proyecto de ley por reconciliación por 56 a 43 unos días después). El día después de la aprobación de la ACA, el 22 de marzo, los republicanos presentaron una legislación para derogarla. [200] Obama convirtió la ACA en ley el 23 de marzo de 2010. [20]
Post-promulgación
Desde su aprobación, los republicanos han votado a favor de derogar total o parcialmente la Ley de Atención Médica Asequible más de sesenta veces. [201]
La Ley de Empleos y Reducción de Impuestos de 2017 eliminó la multa por violar el mandato individual a partir de 2019 (el requisito en sí todavía está vigente). [15] En 2019, el Congreso derogó el llamado impuesto "Cadillac" sobre los beneficios del seguro de salud, un impuesto especial sobre los dispositivos médicos y el Impuesto al Seguro de Salud. [99]
Cobertura de seguro de salud en Estados Unidos por fuente en 2016. La CBO estimó que ACA/Obamacare fue responsable de 23 millones de personas cubiertas a través de intercambios y la expansión de Medicaid. [5]Este gráfico ilustra varios aspectos de la Ley de Atención Médica Asequible, incluido el número de personas cubiertas, el costo antes y después de los subsidios y la opinión pública.
Cobertura
La ley provocó una reducción significativa en el número y porcentaje de personas sin seguro médico. El CDC informó que el porcentaje de personas sin seguro médico cayó del 16,0% en 2010 al 8,9% de enero a junio de 2016. [202] La tasa de personas sin seguro disminuyó en todos los distritos del Congreso de los EE. UU. de 2013 a 2015. [203] La Oficina de Presupuesto del Congreso informó en marzo de 2016 que aproximadamente 12 millones de personas estaban cubiertas por los intercambios (10 millones de las cuales recibieron subsidios) y 11 millones se sumaron a Medicaid. Otro millón estaba cubierto por el "Programa Básico de Salud" de la ACA, para un total de 24 millones. [5] La CBO estimó que la ACA reduciría el número neto de personas sin seguro en 22 millones en 2016, utilizando un cálculo ligeramente diferente para las cifras anteriores que totalizan una cobertura de la ACA de 26 millones, menos 4 millones por reducciones en la "cobertura basada en el empleo" y la "cobertura no grupal y otra". [5]
El Departamento de Salud y Servicios Humanos de los Estados Unidos (HHS) estimó que 20,0 millones de adultos (de 18 a 64 años) obtuvieron cobertura de atención médica a través de la ACA en febrero de 2016; [6] de manera similar, el Urban Institute encontró en 2016 que 19,2 millones de estadounidenses no ancianos obtuvieron cobertura de seguro médico entre 2010 y 2015. [204] En 2016, la CBO estimó que las personas sin seguro eran aproximadamente 27 millones, o alrededor del 10% de la población o entre el 7% y el 8% excluyendo a los inmigrantes no autorizados. [5]
Los estados que ampliaron Medicaid tuvieron una tasa de personas sin seguro del 7,3% en promedio en el primer trimestre de 2016, mientras que los que no lo hicieron tuvieron una tasa del 14,1%, entre los adultos de 18 a 64 años. [205] A diciembre de 2016, 32 estados (incluido Washington DC) habían adoptado la extensión de Medicaid. [206]
Un estudio de 2017 concluyó que la ACA redujo las disparidades socioeconómicas en el acceso a la atención médica. [207]
La Ley de Atención Médica Asequible redujo el porcentaje de estadounidenses entre 18 y 64 años que no tenían seguro médico del 22,3 por ciento en 2010 al 12,4 por ciento en 2016. Alrededor de 21 millones de personas más tienen cobertura diez años después de la promulgación de la ACA. [208] [209] Diez años después de su promulgación, los estudios mostraron que la ACA también tuvo un efecto positivo en la salud y causó una reducción en la mortalidad. [209]
Impuestos
Porcentaje de impuestos especiales 2015
Los impuestos especiales derivados de la Ley de Atención Médica Asequible recaudaron 16.300 millones de dólares en el año fiscal 2015. De ellos, 11.300 millones procedieron de un impuesto especial aplicado directamente a las aseguradoras de salud en función de su cuota de mercado. Se impusieron impuestos especiales anuales por un total de 3.000 millones de dólares a los importadores y fabricantes de medicamentos con receta.
El impuesto individual obligatorio era de 695 dólares por persona o 2.085 dólares por familia como mínimo, y podía llegar hasta el 2,5% de los ingresos del hogar (el que fuera mayor). El impuesto se fijó en 0 dólares a partir de 2019. [210]
En el año fiscal 2018, los mandatos para individuos y empleadores generaron 4 mil millones de dólares cada uno. Los impuestos especiales sobre las aseguradoras y las compañías farmacéuticas sumaron 18 mil millones de dólares. Los recargos al impuesto sobre la renta generaron 437 mil millones de dólares. [211]
La ACA redujo la desigualdad de ingresos medida después de impuestos, debido a los recargos y subsidios al impuesto a la renta. [212] La CBO estimó que los subsidios pagados bajo la ley en 2016 promediaron $4,240 por persona para 10 millones de personas que los recibieron, aproximadamente $42 mil millones. El subsidio impositivo para el mercado de empleadores fue de aproximadamente $1,700 por persona en 2016, o $266 mil millones en total. [5]
Bolsas de seguros
En agosto de 2016, 15 estados operaban su propio mercado de seguros de salud . Otros estados utilizaban el mercado federal o operaban en asociación con el gobierno federal o con el apoyo de este. [213] En 2019, 12 estados y Washington DC operaban sus propios mercados. [214]
En diciembre de 2019, 37 estados (incluido Washington DC) habían adoptado la extensión de Medicaid. [206] Aquellos estados que ampliaron Medicaid tenían una tasa de personas sin seguro del 7,3% en promedio en el primer trimestre de 2016, mientras que los demás tenían una tasa de personas sin seguro del 14,1%, entre los adultos de 18 a 64 años. [205] Tras el fallo de la Corte Suprema en 2012, que sostuvo que los estados no perderían la financiación de Medicaid si no ampliaban Medicaid bajo la ACA, varios estados rechazaron la opción. Más de la mitad de la población nacional sin seguro vivía en esos estados. [215]
Los Centros de Servicios de Medicare y Medicaid (CMS) estimaron que el costo de la expansión fue de $6,366 por persona para 2015, aproximadamente un 49 por ciento por encima de las estimaciones anteriores. Se calcula que entre 9 y 10 millones de personas habían obtenido cobertura de Medicaid, en su mayoría adultos de bajos ingresos. [ cita requerida ] La Kaiser Family Foundation estimó en octubre de 2015 que 3,1 millones de personas adicionales no estaban cubiertas debido a que los estados rechazaron la expansión de Medicaid. [216] [217]
En muchos estados, los umbrales de ingresos estaban significativamente por debajo del 133% de la línea de pobreza. [218] Muchos estados no pusieron Medicaid a disposición de los adultos sin hijos en ningún nivel de ingresos. [219] Debido a que los subsidios en los planes de seguro de intercambio no estaban disponibles para aquellos por debajo de la línea de pobreza, esas personas no tenían nuevas opciones. [220] [221] Por ejemplo, en Kansas, donde solo los adultos no discapacitados con hijos y con un ingreso por debajo del 32% de la línea de pobreza eran elegibles para Medicaid, aquellos con ingresos del 32% al 100% del nivel de pobreza ($6,250 a $19,530 para una familia de tres) no eran elegibles tanto para Medicaid como para los subsidios federales para comprar seguros. Los adultos sin hijos, sin discapacidades, no eran elegibles para Medicaid allí. [215]
Los estudios sobre el impacto de los rechazos a la expansión de Medicaid calcularon que hasta 6,4 millones de personas tendrían demasiados ingresos para Medicaid pero no calificarían para los subsidios de intercambio. [222] Varios estados argumentaron que no podían afrontar la contribución del 10% en 2020. [223] [224] [225] Algunos estudios sugirieron que rechazar la expansión costaría más debido al aumento del gasto en atención de emergencia no compensada que de otro modo habría sido parcialmente pagada por la cobertura de Medicaid, [226] [227]
Un estudio de 2016 concluyó que los residentes de Kentucky y Arkansas, que ampliaron Medicaid, tenían más probabilidades de recibir servicios de atención médica y menos probabilidades de incurrir en gastos de sala de emergencias o tener problemas para pagar sus facturas médicas. Los residentes de Texas, que no aceptaron la ampliación de Medicaid, no vieron una mejora similar durante el mismo período. [228] [229] Kentucky optó por aumentar la atención gestionada, mientras que Arkansas subsidió los seguros privados. Más tarde, los gobernadores de Arkansas y Kentucky propusieron reducir o modificar sus programas. De 2013 a 2015, la tasa de personas sin seguro bajó del 42% al 14% en Arkansas y del 40% al 9% en Kentucky, en comparación con el 39% al 32% en Texas. [228] [230]
Un estudio del DHHS de 2016 concluyó que los estados que ampliaron Medicaid tenían primas más bajas en las pólizas de intercambio, porque tenían menos afiliados de bajos ingresos, cuya salud en promedio es peor que la de aquellos con ingresos más altos. [231]
En septiembre de 2019, la Oficina del Censo informó que los estados que ampliaron Medicaid bajo la ACA tenían tasas de personas sin seguro considerablemente más bajas que los estados que no lo hicieron. Por ejemplo, para los adultos entre el 100% y el 399% del nivel de pobreza, la tasa de personas sin seguro en 2018 fue del 12,7% en los estados que ampliaron la cobertura y del 21,2% en los estados que no la ampliaron. De los 14 estados con tasas de personas sin seguro del 10% o más, 11 no habían ampliado Medicaid. [232] La caída de las tasas de personas sin seguro debido a la ampliación de Medicaid ha ampliado el acceso a la atención entre los adultos de bajos ingresos, y los estudios posteriores a la ACA indican una mejora en la asequibilidad, el acceso a los médicos y las fuentes habituales de atención. [233]
Un estudio que utilizó datos nacionales de la Encuesta de Monitoreo de la Reforma de Salud determinó que las necesidades insatisfechas debido al costo y la incapacidad de pagar las facturas médicas disminuyeron significativamente entre los adultos de bajos ingresos (hasta 138% FPL) y de ingresos moderados (139-199% FPL), y que las necesidades insatisfechas debido al costo disminuyeron aproximadamente 11 puntos porcentuales entre los adultos de bajos ingresos en el segundo período de inscripción. [233] Es importante destacar que los problemas con las necesidades médicas insatisfechas relacionadas con los costos, los medicamentos omitidos, el pago de facturas médicas y el gasto anual de bolsillo se han reducido significativamente entre los adultos de bajos ingresos en los estados de expansión de Medicaid en comparación con los estados sin expansión. [233]
Además, la expansión de Medicaid ha llevado a un aumento del 6,6% en las visitas al médico por parte de adultos de bajos ingresos, así como a un mayor uso de atención preventiva, como visitas al dentista y exámenes de detección de cáncer, entre adultos sin hijos y de bajos ingresos. [233] Se ha encontrado una mejor cobertura de atención médica debido a la expansión de Medicaid en una variedad de poblaciones de pacientes, como adultos con trastornos mentales y por consumo de sustancias, pacientes con traumas, pacientes con cáncer y personas que viven con VIH. [234] [235] [236] [237] En comparación con 2011-13, en 2014 hubo una reducción de 5,4 puntos porcentuales en la tasa de personas sin seguro de adultos con trastornos mentales (del 21,3% al 15,9%) y una reducción de 5,1 puntos porcentuales en la tasa de personas sin seguro de adultos con trastornos por consumo de sustancias (del 25,9% al 20,8%); y los aumentos en la cobertura se produjeron principalmente a través de Medicaid. [237] El uso de tratamiento de salud mental aumentó 2,1 puntos porcentuales, del 43% al 45,1%. [237]
Entre los pacientes con traumatismos de todo el país, la tasa de personas sin seguro ha disminuido aproximadamente un 50%. [234] Los pacientes adultos con traumatismos en los estados de expansión experimentaron una reducción de 13,7 puntos porcentuales en las tasas de personas sin seguro en comparación con los pacientes adultos con traumatismos en los estados sin expansión, y un aumento acompañante de 7,4 puntos porcentuales en el alta para rehabilitación. [238] Tras la expansión de Medicaid y la expansión de la cobertura para dependientes, los adultos jóvenes hospitalizados por lesiones traumáticas agudas en Maryland experimentaron un aumento del 60% en la rehabilitación, una reducción del 25% en la mortalidad y una reducción del 29,8% en la falta de rescate. [239] El rápido impacto de la expansión de Medicaid en los pacientes con cáncer se demostró en un estudio que utilizó el programa de Vigilancia, Epidemiología y Resultados Finales (SEER) del Instituto Nacional del Cáncer que evaluó a más de 850.000 pacientes diagnosticados con cáncer de mama, pulmón, colorrectal, próstata o cáncer de tiroides de 2010 a 2014. El estudio encontró que un diagnóstico de cáncer en 2014 se asoció con una disminución absoluta de 1,9 puntos porcentuales y una disminución relativa de 33,5% en las tasas de personas sin seguro en comparación con un diagnóstico realizado entre 2010 y 2013. [236] Otro estudio, que utilizó datos del Programa de Vigilancia, Epidemiología y Resultados Finales (SEER) de 2010 a 2014, encontró que la expansión de Medicaid se asoció con un aumento neto de 6,4% en los diagnósticos de etapa temprana (in situ, local o regional) de todos los cánceres combinados. [240]
Los datos del Proyecto de Monitoreo Médico de los Centros para la Prevención y las Enfermedades (CDC) demostraron que entre 2009 y 2012, aproximadamente el 18% de las personas que viven con VIH (PLWH) que estaban recibiendo tratamiento contra el VIH de forma activa no tenían seguro [241] y que al menos el 40% de los adultos infectados por VIH que recibían tratamiento estaban asegurados a través de Medicaid y/o Medicare, programas para los que calificaban solo una vez que su enfermedad estaba lo suficientemente avanzada como para ser cubierta como una discapacidad por el Seguro Social. [241] La cobertura ampliada de Medicaid de las PLWH se ha asociado positivamente con resultados de salud como la supresión viral, la retención de la atención, las tasas de hospitalización y la morbilidad en el momento de la hospitalización. [235] Un análisis de los datos de la encuesta del Sistema de Vigilancia de Factores de Riesgo Conductual (BRFSS) encontró un aumento anual del 2,8% en las tasas de supresión viral entre todas las PLWH de 2010 a 2015 debido a la expansión de Medicaid. [242] En Nebraska, las personas que viven con el VIH recientemente cubiertas por la expansión de Medicaid en 2013-14 tenían cuatro veces más probabilidades de tener supresión viral que las personas que eran elegibles pero seguían sin seguro. [242] Como uno de los primeros en adoptar la expansión de Medicaid, Massachusetts encontró una tasa de supresión viral del 65% entre todas las personas que viven con el VIH y una tasa del 85% entre las que se mantuvieron en el sistema de atención médica en 2014, ambas sustancialmente más altas que el promedio nacional. [242]
Un análisis de los datos de egresos hospitalarios de 2012 a 2014 en cuatro estados de expansión de Medicaid y dos estados sin expansión reveló que las hospitalizaciones de personas que viven con el VIH sin seguro cayeron del 13,7% al 5,5% en los cuatro estados de expansión y aumentaron del 14,5% al 15,7% en los dos estados sin expansión. [243] Es importante destacar que las personas que viven con el VIH sin seguro tenían un 40% más de probabilidades de morir en el hospital que las personas que viven con el VIH con seguro. [243] Otros resultados de salud notables asociados con la expansión de Medicaid incluyen mejores tasas de monitoreo de glucosa para pacientes con diabetes, mejor control de la hipertensión y tasas reducidas de morbilidad posoperatoria importante. [244]
Un estudio de julio de 2019 realizado por la Oficina Nacional de Investigación Económica (NBER, por sus siglas en inglés) indicó que los estados que implementaron la expansión de Medicaid exhibieron reducciones estadísticamente significativas en las tasas de mortalidad. [245] De ese estudio, los estados que implementaron la expansión de Medicaid "salvaron las vidas de al menos 19.200 adultos de 55 a 64 años durante el período de cuatro años de 2014 a 2017". [246] Además, 15.600 adultos mayores murieron prematuramente en los estados que no implementaron la expansión de Medicaid en esos años según la investigación de la NBER. "Los impactos de la expansión de Medicaid en la salvación de vidas son grandes: se estima que se reduce entre el 39 y el 64 por ciento las tasas de mortalidad anuales de los adultos mayores que obtienen cobertura". [246]
Debido a que muchos estados no lograron expandirse, muchos demócratas copatrocinaron la propuesta Ley Cover Now 2021 que permitiría a los gobiernos de los condados y municipios financiar la expansión de Medicaid. [247]
Expansión de Medicaid por estado
Costos de seguro
[249]
National health care expenditures rose faster than national income both before (2009–2013: 3.73%) and after (2014–2018: 4.82%) ACA's major provisions took effect.[250][249] Premium prices rose considerably before and after. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas.[251] However, some or all these costs were offset by tax credits. For example, the Kaiser Family Foundation reported that for the second-lowest cost "Silver plan", a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the tax credit, despite a large increase in the list price. This was consistent nationally. In other words, the subsidies increased along with the premium price, fully offsetting the increases for subsidy-eligible enrollees.[252]
Premium cost increases in the employer market moderated after 2009. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015,[7] with only a 3% increase from 2015 to 2016.[253] From 2008 to 2010 (before passage of ACA) health insurance premiums rose by an average of 10% per year.[254]
Several studies found that the financial crisis and accompanying recession could not account for the entirety of the slowdown and that structural changes likely shared at least partial credit.[255][256][257][258] A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation.[259][clarification needed] Paul Krawzak claimed that even if cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly the growth of the population on Medicare.[260]
In a 2016 review, Barack Obama claimed that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.[261]
Deductibles and co-payments
A contributing factor to premium cost moderation was that the insured faced higher deductibles, copayments and out-of-pocket maximums. In addition, many employees chose to combine a health savings account with higher deductible plans, making the net impact of ACA difficult to determine precisely.
For the group market (employer insurance), a 2016 survey found that:
Deductibles grew 63% from 2011 to 2016, while premiums increased 19% and worker earnings grew by 11%.
In 2016, 4 in 5 workers had an insurance deductible, which averaged $1,478. For firms with less than 200 employees, the deductible averaged $2,069.
The percentage of workers with a deductible of at least $1,000 grew from 10% in 2006 to 51% in 2016. The 2016 figure dropped to 38% after taking employer contributions into account.[262]
For the non-group market, of which two-thirds are covered by ACA exchanges, a survey of 2015 data found that:
49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
Many exchange enrollees qualify for cost-sharing subsidies that reduce their net deductible.
While about 75% of enrollees were "very satisfied" or "somewhat satisfied" with their choice of doctors and hospitals, only 50% had such satisfaction with their annual deductible.
While 52% of those covered by ACA exchanges felt "well protected" by their insurance, in the group market 63% felt that way.[263]
Health outcomes
According to a 2014 study, ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.[264] Himmelstein and Woolhandler wrote in January 2017 that a rollback of ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.[265]
According to the Kaiser Foundation, expanding Medicaid in the remaining states would cover up to 4.5 million persons.[266] A 2021 study found a significant decline in mortality rates in the states that opted in to the Medicaid expansion program compared with those states that did not do so. The study reported that states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017.[267][268]
Dependent Coverage Expansion (DCE) under the ACA has had a demonstrable effect on various health metrics of young adults, a group with a historically low level of insurance coverage and utilization of care.[269] Numerous studies have shown the target age group gained private health insurance relative to an older group after the policy was implemented, with an accompanying improvement in having a usual source of care, reduction in out-of-pocket costs of high-end medical expenditures, reduction in frequency of Emergency Department visits, 3.5% increase in hospitalizations and 9% increase in hospitalizations with a psychiatric diagnosis, 5.3% increase in utilizing specialty mental health care by those with a probable mental illness, 4% increase in reporting excellent mental health, and a 1.5-6.2% increase in reporting excellent physical health.[269] Studies have also found that DCE was associated with improvements in cancer prevention, detection, and treatment among young adult patients.[240][270] A study of 10,010 women aged 18–26 identified through the 2008-12 National Health Interview Survey found that the likelihood of HPV vaccination initiation and completion increased by 7.7 and 5.8 percentage points respectively when comparing before and after October 1, 2010.[270] Another study using National Cancer Database (NCDB) data from 2007 to 2012 found a 5.5 percentage point decrease in late-stage (stages III/IV) cervical cancer diagnosis for women aged 21–25 after DCE, and an overall decrease of 7.3 percentage points in late-stage diagnosis compared to those aged 26–34.[240] A study using SEER Program data from 2007 to 2012 found a 2.7 percentage point increase in diagnosis at stage I disease for patients aged 19–25 compared with those aged 26–34 for all cancers combined.[240] Studies focusing on cancer treatment after DCE found a 12.8 percentage point increase in the receipt of fertility-sparing treatment among cervical cancer patients aged 21–25 and an overall increase of 13.4 percentage points compared to those aged 26–34, as well as an increased likelihood that patients aged 19–25 with stage IIB-IIIC colorectal cancer receive timely adjuvant chemotherapy compared to those aged 27–34.[240]
Two 2018 JAMA studies found the Hospital Readmissions Reduction Program (HRRP) was associated with increased post-discharge mortality for patients hospitalized for heart failure and pneumonia.[271][272][273] A 2019 JAMA study found that ACA decreased emergency department and hospital use by uninsured individuals.[274] Several studies have indicated that increased 30-day, 90-day, and 1-year post-discharge mortality of heart failure patients can be attributed to "gaming the system" through inappropriate triage systems in emergency departments, use of observation stays when admissions are warranted, and delay of readmission beyond the 30th day post-discharge, strategies that can reduce readmission rates at the expense of quality of care and patient survival.[275] The HRRP was also shown to disproportionately penalize safety-net hospitals that predominately serve low-income patients.[276] A 2020 study by Treasury Department economists in the Quarterly Journal of Economics using a randomized controlled trial (the IRS sent letters to some taxpayers noting that they had paid a fine for not signing up for health insurance but not to other taxpayers) found that over two years, obtaining health insurance reduced mortality by 12 percent.[277][278] The study concluded that the letters, sent to 3.9 million people, may have saved 700 lives.[277]
A 2020 JAMA study found that Medicare expansion under the ACA was associated with reduced incidence of advanced-stage breast cancer, indicating that Medicaid accessibility led to early detection of breast cancer and higher survival rates.[279] Recent studies have also attributed to Medicaid expansion an increase in use of smoking cessation medications, cervical cancer screening, and colonoscopy, as well as an increase in the percentage of early-stage diagnosis of all cancers and the rate of cancer surgery for low-income patients.[280][281] These studies include a 2.1% increase in the probability of smoking cessation in Medicaid expansion states compared to non-expansion states, a 24% increase in smoking cessation medication use due to increased Medicaid-financed smoking cessation prescriptions, a 27.7% increase in the rate of colorectal cancer screening in Kentucky following Medicaid expansion with an accompanying improvement in colorectal cancer survival, and a 3.4% increase in cancer incidence following Medicaid expansion that was attributed to an increase in early-stage diagnoses.[280]
Transition-of-care interventions and Alternative Payment Models under the ACA have also shown promise in improving health outcomes.[282][283] Post-discharge provider appointment and telephone follow-up interventions have been shown to reduce 30-day readmission rates among general medical-surgical inpatients.[282] Reductions in 60, 90, and 180 post-discharge day readmission rates due to transition-of-care interventions have also been demonstrated, and a reduction in 30-day mortality has been suggested.[282] Total joint arthroplasty bundles as part of the Bundled Payments for Care Improvement initiative have been shown to reduce discharge to inpatient rehabilitation facilities and post-acute care facilities, decrease hospital length of stay by 18% without sacrificing quality of care, and reduce the rate of total joint arthroplasty readmissions, half of which were due to surgical complications.[283] The Hospital Value-Based Purchasing Program in Medicaid has also shown the potential to improve health outcomes, with early studies reporting positive and significant effects on total patient experience score, 30-day readmission rates, incidences of pneumonia and pressure ulcers, and 30-day mortality rates for pneumonia.[284] The patient-centered medical home (PCMH) payment and care model, a team-based approach to population health management that risk-stratifies patients and provides focused care management and outreach to high-risk patients, has been shown to improve diabetes outcomes.[285] A widespread PCMH demonstration program focusing on diabetes, known as the Chronic Care Initiative in the Commonwealth of Pennsylvania, found statistically significant improvements in A1C testing, LDL-C testing, nephropathy screening and monitoring, and eye examinations, with an accompanying reduction in all-cause emergency department visits, ambulatory care-sensitive emergency department visits, ambulatory visits to specialists, and a higher rate of ambulatory visits to primary care providers.[285] The ACA overall has improved coverage and care of diabetes, with a significant portion of the 3.5 million uninsured US adults aged 18–64 with diabetes in 2009-10 likely gaining coverage and benefits such as closure of the Medicaid Part D coverage gap for insulin.[286] 2.3 million of the approximately 4.6 million people aged 18–64 with undiagnosed diabetes in 2009–2010 may also have gained access to zero-cost preventative care due to section 2713 of the ACA, which prohibits cost sharing for United States Preventive Services Taskforce grade A or B recommended services, such as diabetes screenings.[286]
Distributional impact
The distributional impact of the Affordable Care Act (ACA or Obamacare) during 2014. ACA raised taxes mainly on the top 1% to fund approximately $600 in benefits on average for the bottom 40% of families.
In March 2018, the CBO reported that ACA had reduced income inequality in 2014, saying the law led the lowest and second quintiles (the bottom 40%) to receive an average of an additional $690 and $560 respectively while causing households in the top 1% to pay an additional $21,000 due mostly to the net investment income tax and the additional Medicare tax. The law placed relatively little burden on households in the top quintile (top 20%) outside of the top 1%.[10]
Federal deficit
CBO estimates of revenue and impact on deficit
The CBO reported in multiple studies that ACA would reduce the deficit, and repealing it would increase the deficit, primarily because of the elimination of Medicare reimbursement cuts.[8][9] The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:[9][287] it calculated the law would result in $604 billion in total outlays offset by $813 billion in total receipts, resulting in a $210 billion net deficit reduction.[9] The CBO separately predicted that while most of the spending provisions do not begin until 2014,[288][289] revenue would exceed spending in those subsequent years.[290][dead link] The CBO claimed the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs"[291]—ultimately extending the solvency of the Medicare trust fund by eight years.[292]
This estimate was made prior to the Supreme Court's ruling that enabled states to opt out of the Medicaid expansion, thereby forgoing the related federal funding. The CBO and JCT subsequently updated the budget projection, estimating the impact of the ruling would reduce the cost estimate of the insurance coverage provisions by $84 billion.[293][294][295]
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 feedback effects. The CBO also forecast that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2025, mainly by boosting the supply of labor.[8]
Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion.[291][296] 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".[297]
In 2017 CBO estimated that repealing the individual mandate alone would reduce the 10-year deficit by $338 billion.[298]
Opinions on CBO projections
The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019.[299][300][301] However, the so-called "doc fix" is a separate issue that would have existed with or without ACA.[302][303][304] The Center on Budget and Policy Priorities objected that Congress had a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings, although not the doc fix.[305][306] The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.[307]
Health economistUwe Reinhardt, wrote, "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation."[308]Douglas Holtz-Eakin alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.[309]
Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from preventive healthcare, and that the CBO had a track record of overestimating costs and underestimating savings of health legislation;[310][311] stating, "innovations in the delivery of medical care, like greater use of electronic medical records[312] 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."[310]
In 2010 David Walker said the CBO estimates were not likely to be accurate, because they were based on the assumption that the law would not change.[313]
Employer mandate and part-time work
The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers.[314] Critics claimed it created a perverse incentive to hire part-timers instead.[315][316] However, between March 2010 and 2014, the number of part-time jobs declined by 230,000 while the number of full-time jobs increased by two million.[317][318] In the public sector full-time jobs turned into part-time jobs much more than in the private sector.[317][319] A 2016 study found only limited evidence that ACA had increased part-time employment.[320]
Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees,[321][unreliable source?][322][unreliable source?] to reflect the 30-hour-or-more definition for full-time worker.[314] As of 2013, few companies had shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).[316] Trends in working hours[323] and the recovery from the Great Recession correlate with the shift from part-time to full-time work.[324][325] Other confounding impacts include that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and lowers corresponding training and administration costs from a smaller, more stable workforce.[316][323][326] Relatively few firms employ over 50 employees[316] and more than 90% of them already offered insurance.[327]
Most policy analysts (both right and left) were critical of the employer mandate provision.[315][327] They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful;[328][329] that the raised marginal cost of the 50th worker for businesses could limit companies' growth;[330] that the costs of reporting and administration were not worth the costs of maintaining employer plans;[328][329] and noted that the employer mandate was not essential to maintain adequate risk pools.[331][332] The provision generated vocal opposition from business interests and some unions who were not granted exemptions.[329][333]
Hospitals
From the start of 2010 to November 2014, 43 hospitals in rural areas closed. Critics claimed the new law had caused these closures. Many rural hospitals were built using funds from the 1946 Hill–Burton Act. Some of these hospitals reopened as other medical facilities, but only a small number operated emergency rooms (ER) or urgent care centers.[334]
Between January 2010 and 2015, a quarter of ER doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured.[335] Michael Lee Jr. and Michael C. Monuteaux at Boston Children's Hospital analyzed national emergency department visits among children aged 0 to 17 from 2009 to 2016 using the American Community Survey (ACS) and Nationwide Emergency Department Sample (NEDS). They found no immediate change in pediatric emergency department visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends, almost 10%.[336]
Several large insurers formed ACOs. Many hospitals merged and purchased physician practices, amounting to a significant consolidation of the provider industry. The increased market share gave them more leverage with insurers and reduced patient care options.[112]
Economic consequences
Coverage rate, employer market cost trends, budgetary impact, and income inequality aspects of the Affordable Care Act
CBO estimated in June 2015 that repealing ACA would:
Decrease GDP in the short-term, as government spending (on subsidies) was only partially replaced by spending by recipients.
Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021–2025 period. CBO cited ACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing ACA would remove those disincentives, encouraging workers to supply more labor, increasing the total number of hours worked by about 1.5% over the 2021–2025 period.
Remove the higher tax rates on capital income, thereby encouraging investment, raising the capital stock and output in the long-run.[8]
In 2015 the progressive Center for Economic and Policy Research found no evidence that companies were reducing worker hours to avoid ACA requirements[337] for employees working more than 30 hours per week.[338]
CBO estimated that ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Jonathan Cohn claimed that ACA's primary employment effect was to alleviate job lock[339] and the reform's only significant employment impact was the retirement of those who were working only to stay insured.[340]
Public opinion
Congressional Democrats celebrate the 6th anniversary of the Affordable Care Act on the steps of the Capitol.
Public views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Approval varied by party, race and age. Some elements were more widely favored (preexisting conditions) or opposed (individual mandate).
In a 2010 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.[341] Other polls found that people were concerned the law would cost more than projected and would not do enough to control costs.[342]
In a 2012 poll 44% supported the law, with 56% against. By 75% of Democrats, 27% of Independents and 14% of Republicans favored the law. 82% favored banning insurance companies from denying coverage to people with preexisting conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.[343] Other polls showed additional provisions receiving majority support, including the exchanges, pooling small businesses and the uninsured with other consumers and providing subsidies.[344][345]
Some opponents believed the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.[343]
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".[346] 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".[347]
As of October 2013, approximately 40% were in favor while 51% were against.[348][349] About 29% of whites approved of the law, compared with 61% of Hispanics and 91% of African Americans.[350] A solid majority of seniors opposed the idea and a solid majority of those under forty were in favor.[351]
A 2014 poll reported that 26% of Americans support ACA.[352] A later 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA versus 38.3% who had a favorable view (of more than 5,500 individuals).[353] Another held that 8% of respondents agreed the Affordable Care Act "is working well the way it is".[354] In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.[355]
In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved.[356] A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.[357]
Separate polls from Fox News and NBC/WSJ, both taken during January 2017, indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who had once opposed it (many still prefer "Medicare for all") shifted their positions because ACA was under threat of repeal.[358] Another January 2017 poll reported that 35% of respondents believed "Obamacare" and the "Affordable Care Act" were different or did not know. (About 45% were unsure whether "repeal of Obamacare" also meant "repeal of the Affordable Care Act".) 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the ACA were repealed and no replacement enacted", with Democrats far more likely (79%) to know that fact than Republicans (47%).[359] A 2017 study found that personal experience with public health insurance programs led to greater support for the ACA, most prominently among Republicans and low-information voters.[360]
By the end of 2023, a Morning Consult poll of registered voters found that 57% approved of the Affordable Care Act, while 30% disapproved of it. 85% of Democrats, 56% of independents, and 28% of Republicans supported the law.[361]
Political aspects
"Obamacare"
The term "Obamacare" was originally coined by opponents as a pejorative. According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured.[362] The term officially emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott wrote, "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care', 'Edwards-care', and a totally revamped and remodeled 'Hillary-care' from the 1990s".[363][364]
In May 2007, Mitt Romney introduced it to political discourse, saying, "How can we get those people insured without raising taxes and without having government take over healthcare?' And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."[363]
By mid-2012, Obamacare had become the colloquial term used both by supporters and opponents.[362] Obama eventually endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."[365]
The use of "Obamacare" became increasingly rare, and at the 2024 Democratic National Convention, Obama said, "I noticed, by the way, since it became popular, they don't call it 'Obamacare' no more."[366]
Common misconceptions
"Death panels"
On August 7, 2009, Sarah Palin created the term "death panels" to describe groups who would decide whether sick patients were "worthy" of medical care.[367] "Death panel" referred to two claims about early drafts.
One was that under the law, seniors could be denied care due to their age[368] 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).[369] IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when statutory expenditure levels were exceeded within any given three-year period. In fact, the Board was prohibited from recommending changes that would reduce payments before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.[370][371]
The other related issue concerned advance-care planning consultation: a section of the House reform proposal would have reimbursed physicians for providing patient-requested consultations for Medicare recipients on end-of-life health planning (which is covered by many private plans), enabling patients to specify, on request, the kind of care they wished to receive.[372] The provision was not included in ACA.[373]
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.[374] The allegation was named PolitiFact's 2009 "Lie of the Year",[367][375] one of FactCheck.org's "whoppers"[376][377] and the most outrageous term by the American Dialect Society.[378] AARP described such rumors as "rife with gross—and even cruel—distortions".[379]
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).[380][381]
Illegal immigrants
ACA explicitly denies insurance subsidies to "unauthorized (illegal) aliens".[55][56][382]
Exchange "death spiral"
Opponents claimed that combining immediate coverage with no provision for preexisting conditions would lead people to wait to get insured until they got sick. The individual mandate was designed to push people to get insured without waiting. This has been called a "death spiral".[383] In the years after 2013, many insurers did leave specific marketplaces, claiming the risk pools were too small.
The median number of insurers per state was 4.0 in 2014, 5.0 in 2015, 4.0 in 2016 and 3.0 in 2017. Five states had one insurer in 2017, 13 had two, 11 had three; the remainder had four or more.[384]
"If you like your plan"
At various times during and after ACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan."[385][386] However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,[387] and several million more risked seeing their current plans canceled.[388][389]
Obama's previous unambiguous assurance that consumers could keep their own plans became a focal point for critics, who challenged his truthfulness.[390][391] Various bills were introduced in Congress to allow people to keep their plans.[392]
PolitiFact initially cited various estimates that only about 2% of the total insured population (4million out of 262 million) received such notices,[393] but readers later voted Obama's claims as the 2013 "Lie of the Year".[394]
Criticism and opposition
Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions,[333][395]conservative advocacy groups,[396][397] Republicans, small business organizations and the Tea Party movement.[398] These groups claimed the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit.[399] Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods.[400][401] President Donald Trump repeatedly promised to "repeal and replace" it.[402][403]
As of 2013[update] unions that expressed concerns included the AFL–CIO,[404] which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, whose leaders sent a letter to Reid and Pelosi arguing, "PPACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class."[333] In January 2014, Terry O'Sullivan, president of the Laborers' International Union of North America (LIUNA) and D. Taylor, president of Unite Here sent a letter to Reid and Pelosi stating, "ACA, as implemented, undermines fair marketplace competition in the health care industry."[395]
In October 2016, Mark Dayton, the governor of Minnesota and a member of the Minnesota Democratic–Farmer–Labor Party, said ACA had "many good features" but it was "no longer affordable for increasing numbers of people"; he called on the state legislature to provide emergency relief to policyholders.[405] Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.[406]
Legal challenges
National Federation of Independent Business v. Sebelius
Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds.[407][408][failed verification] The Supreme Court ruled, 5–4, that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.
The Court further determined that states could not be forced to expand Medicaid. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.[12]
In Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice Clarence Thomas said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the [administration], that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice Elena Kagan filed a concurring opinion in the judgment, in which Stephen Breyer joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."[411]
In a later lawsuit brought by private health insurance buyers and businesses, Judge Reed O'Connor of the Federal District Court for the Northern District of Texas ruled in March 2023 that the ACA's provision of contraceptives, HIV testing, and screenings for cancer, diabetes, and mental health violated the plaintiffs' freedom of religious exercise, and placed an injunction on that portion of the ACA. The Biden administration planned to seek a hold on O'Connor's decision.[412]
King v Burwell
On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.[413]
House v. Price
House Republicans sued the Obama administration in 2014, alleging that cost-sharing reduction subsidy payments to insurers were unlawful because Congress had not appropriated funds to pay for them. The argument classified the CSR subsidy as discretionary spending subject to annual appropriation. In May 2016, a federal judge ruled for the plaintiffs, but the Obama administration appealed.[414] Later, President Trump ended the payments. This led to further litigation.[415]
United States House of Representatives v. Azar
The House sued the administration, alleging that the money for CSRs to insurers had not been appropriated, as required for any federal government spending. The ACA subsidy that helps customers pay premiums was not part of the suit.
Without the CSRs, the government estimated that premiums would increase by 20% to 30% for silver plans.[416] In 2017, the uncertainty about whether the payments would continue caused Blue Cross Blue Shield of North Carolina to try to raise premiums by 22.9% the next year, as opposed to an increase of 8.8% that it would have sought if the payments were assured.[417]
U.S. District Judge Rosemary M. Collyer ruled that the cost-sharing program was unconstitutional for spending money that has not been specifically provided by an act of Congress, but concluded that Congress had in fact authorized that program to be created. The judge also found that Congress had provided authority to cover the spending for the tax credits to consumers who use them to help afford health coverage.[418] Collyer enjoined further cost-sharing payments, but stayed the order pending appeal to the United States Court of Appeals for the District of Columbia Circuit. The case ended in a settlement before the Circuit Court.
California v. Texas
Texas and 19 other states filed a civil suit in the United States District Court for the Northern District of Texas in February 2018, arguing that with the passage of the Tax Cuts and Jobs Act of 2017, which eliminated the tax for not having health insurance, the individual mandate no longer had a constitutional basis and thus the entire ACA was no longer constitutional.[419] The Department of Justice said it would no longer defend the ACA in court, but 17 states led by California stepped in to do so.[420]
District Judge Reed O'Connor of Texas ruled for the plaintiffs on December 14, 2018, writing that the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional." He then further reasoned that the individual mandate is an essential part of the entire law, and thus was not severable, making the entire law unconstitutional.[421][422] O'Connor's decision regarding severability turned on several passages from the Congressional debate that focused on the importance of the mandate.[423] While he ruled the law unconstitutional, he did not overturn the law.[420]
The intervening states appealed the decision to the Fifth Circuit. These states argued that Congress's change in the tax was only reducing the amount of the tax, and that Congress had the power to write a stronger law to this end.[424][425] O'Connor stayed his decision pending the appeal.[426] The Fifth Circuit heard the appeal on July 9, 2019; in the interim, the U.S. Department of Justice joined with Republican states to argue that the ACA was unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. An additional question was addressed, as the Republican plaintiffs challenged the Democratic states' standing to defend the ACA.[427]
In December 2019, the Fifth Circuit agreed the individual mandate was unconstitutional, but did not agree that the entire law should be voided. Instead, it remanded the case to the District Court for reconsideration of that question.[428] The Supreme Court accepted the case in March 2020, to be heard in the 2020–2021 term,[429] with the ruling likely falling after the 2020 elections.[430]
Democrats pointed out that the effect of invalidating the entire law would be to remove popular provisions such as the protection for preexisting conditions, and that the Republicans had still not offered any replacement plan—important issues in the 2020 elections.[430]
On June 17, 2021, the Court rejected the challenge in a 7–2 decision, ruling that Texas and the other plaintiff states did not have standing to challenge the provision, leaving the full ACA intact.[431][432][433]
Risk corridors
The Supreme Court ruled that promised risk corridor payments must be made even in the absence of specific appropriation of money by Congress.[86]
Non-cooperation
Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements over which they had discretion.[434][435] For example, Missouri declined to expand Medicaid or establish a health insurance marketplace engaging in active non-cooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law.[436] Other Republicans discouraged efforts to advertise the law's benefits. Some conservative political groups launched ad campaigns to discourage enrollment.[437][438]
Repeal and modification efforts
ACA was the subject of many unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives Steve King and Michele Bachmann introduced bills in the House to repeal the ACA the day after it was signed, as did Senator Jim DeMint in the Senate.[439] In 2011, after Republicans gained control of the House, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189.[440] All Republicans and three Democrats voted for repeal.[441] In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down.[442] President Obama said he would veto the bill had it passed.[443]
2017 House Budget
On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.[444]
2013 federal government shutdown
Strong partisan disagreement in Congress prevented adjustments to the Act's provisions.[445] But at least one change, a proposed repeal of a tax on medical devices, received bipartisan support.[446] Some Congressional Republicans argued against improvements to the law on the grounds that they would weaken the arguments for repeal.[329][447]
Republicans attempted to defund the ACA's implementation,[435][448] and in October 2013 House Republicans refused to fund the federal government unless it came with an implementation delay, after Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay the ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership said the Senate would pass only a bill without any restrictions on ACA. The government shutdown lasted from October 1 to October 17.[449][450][451]
2017 repeal effort
McCain votes no on repealing the Affordable Care Act by giving a thumbs down.
During a midnight congressional session starting January 11, the Senate of the 115th Congress of the United States voted to approve a "budget blueprint" that would allow Republicans to repeal parts of the law "without threat of a Democraticfilibuster".[452][453] The plan, which passed 51–48, was named by Senate Republicans the "Obamacare 'repeal resolution.'"[454] Democrats opposing the resolution staged a protest during the vote.[455]
House Republicans announced their replacement, the American Health Care Act, on March 6.[456] On March 24, the AHCA failed amid a revolt among Republican representatives.[457]
On May 4 the House voted to pass the AHCA by a margin of 217 to 213.[458] The Senate Republican leadership announced that Senate Republicans would write their own version of the bill instead of voting on the House version.[459]
Leader McConnell named a group of 13 Republicans to draft the substitute version in private, raising bipartisan concerns about lack of transparency.[460][461][462] On June 22, Republicans released the first discussion draft, which renamed it the "Better Care Reconciliation Act of 2017" (BCRA).[463] On July 25, although no amendment proposal had garnered majority support, Republicans voted to advance the bill to the floor and begin formal consideration of amendments. Senators Susan Collins and Lisa Murkowski were the only two dissenting Republicans, making the vote a 50–50 tie. Vice President Mike Pence then cast the tie-breaking vote in the affirmative.[464]
The revised BCRA failed, 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but that too failed, 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to ACA, failed by 49–51, with Collins, Murkowski, and McCain joining all Democrats and independents in voting against it.[465]
Proposed changes in 2024
Donald Trump, who has historically opposed the ACA,[466][467][468] has said during the 2024 United States presidential debatesthat he plans to modify or scrap sections it, saying he has "proposals." JD Vance has said that Trump intends to allow insurance companies to discriminate against people with preexisting conditions or disability, with subsidized insurance replaced with private insurance.[469][470][471] Kamala Harris has said she will "maintain and grow" the ACA.[472][473]
Actions to hinder implementation
Tax Cuts and Jobs Act—number of additional persons uninsured[474]
Under both the ACA (current law) and the AHCA, the CBO reported that the health exchange marketplaces would remain stable.[475] But Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums.[476] Concern about the exchanges became another argument for reforms. Past and ongoing Republican attempts to weaken the law have included:
President Trump ended the payment of cost-sharing reduction subsidies to insurers on October 12, 2017. CBO estimated in September 2017 that discontinuing the payments would add an average of 15–20 percentage points to health insurance costs on the exchanges in 2018 while increasing the budget deficit nearly $200 billion over a decade.[477] In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019.[415] 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.[478][479] The insurers would need to make up the $7 billion they had previously received in cost-sharing reductions (CSRs) by raising premiums. Since most premiums are subsidized, the federal government would cover most of the increases. CBO also estimated that initially up to one million fewer people would have health insurance coverage, although rising subsidies might eventually offset this. The 85% of enrollees who received subsidies would be unaffected. CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level.[480] Several insurance companies who sued the United States for failure to pay CSRs won cases in 2018 and 2019. The judiciary decided the insurance companies are entitled to unpaid CSRs.[415][481]
The 2015 appropriations bill had a rider that ended the payment of risk corridor funds. This was repeated in later years. This resulted in the bankruptcy of many co-ops. This action was attributed to Senator Marco Rubio.[482] The cutoff generated some 50 lawsuits. The Supreme Court granted certiorari in 2019 in the case Maine Community Health Options v. United States.[483][484][485]
Trump weakened the individual mandate with his first executive order, which limited enforcement of the tax. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding Obama's instructions to reject them.[486]
Trump reduced funding for advertising for exchange enrollment by up to 90%, with other reductions to support resources used to answer questions and help people sign-up for coverage.[487] The CBO said the reductions would reduce ACA enrollment.[477]
Trump reduced the enrollment period for 2018 by half, to 45 days.[488]
Trump made public statements that the exchanges were unstable or in a death spiral.[489]
Socialism debate
Many economically conservative opponents called the ACA "socialist" or "socialized medicine", pointing to the government redistribution of wealth via subsidies for low-income purchasers, expansion of the government-run Medicaid insurance, government requirements as to what products can be sold on the exchanges, and the individual mandate, which reduces freedom of consumer choice to be uninsured.[490][491][492]
Other observers considered the law a relatively capitalist or "regulated free-market" means of paying for near-universal health care, because it creates new marketplaces with choices for consumers, largely relies on private employers and private health insurance companies, maintains private ownership of hospitals and doctor's offices, and was originally advocated for by economic conservatives as a capitalist alternative to single-payer health care.[493][494][495] Some pointed out that the previous system also had socialist aspects. Even for-profit private health insurance companies socialize risk and redistribute wealth from people who have it (all premium payers) to those who need it (by paying for medically necessary healthcare).[495] The requirement to provide emergency care also forced redistribution from people who pay insurance premiums to those who choose to be uninsured, when they visit the emergency room.[494]
Some Obamacare supporters accused conservatives of using the term "socialism" as a scare tactic for Obamacare as it was for Medicare and Medicaid,[495] and some embraced the label "socialism" as desirable, distinguishing democratic socialism as most desirable for education and health care,[496] and communism as undesirable.[495] Milos Forman opined that critics "falsely equate Western European-style socialism, and its government provision of social insurance and health care, with Marxist–Leninist totalitarianism".[497]
Implementation
In 2010 small business tax credits took effect.[498] Then Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those who had been denied coverage by private insurance companies because of a preexisting condition.[498] By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement.[499] In National Federation of Independent Business v. Sebelius the Supreme Court allowed states to opt out of the Medicaid expansion.[500][501][502]
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.[503][504] On July2 Obama delayed the employer mandate until 2015.[327][505][506] The launch for both the state and federal exchanges was beset by management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered many problems.[507] Operations stabilized in 2014, although not all planned features were complete.[508][509]
The Government Accountability Office released a non-partisan study in 2014 that concluded the administration had not provided "effective planning or oversight practices" in developing the exchanges.[510] In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.[511] At the beginning of the 2015, 11.7 million had signed up (ex-Medicaid).[512] By the end of the year about 8.8 million consumers had stayed in the program.[513] Congress repeatedly delayed the onset of the "Cadillac tax" on expensive insurance plans first until 2020[514] and later until 2022 and repealed it in late 2019.[99]
An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults. The five major national insurers expected to lose money on ACA policies in 2016,[515] in part because the enrollees were lower income, older and sicker than expected.[516]
More than 9.2 million people (3.0 million new customers and 6.2 million returning) enrolled on the national exchange in 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump.[517] The eleven states that run their own exchanges signed up about 3million more.[517] The IRS announced that it would not require that tax returns indicate a person has health insurance, reducing the effectiveness of the individual mandate, in response to Trump's executive order.[518] The CBO reported in March that the healthcare exchanges were expected to be stable.[475] In May the House voted to repeal the ACA using the American Health Care Act (AHCA), but the AHCA was defeated in the Senate.[519][520] The Tax Cuts and Jobs Act set the individual mandate penalty at $0 starting in 2019.[59] The CBO estimated that the change would cause 13 million fewer people to have health insurance in 2027.[521]
The 2017 Individual Market Stabilization Bill was proposed to fund cost cost-sharing reductions,[522] provide more flexibility for state waivers, allow a new "Copper Plan" offering only catastrophic coverage, allow interstate insurance compacts, and redirect consumer fees to states for outreach. The bill failed.
By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicaid or via an alternative program.[523]
In popular culture
SNL presented a sketch in October 2009 about the legislation's gridlock, with Dwayne Johnson playing an angry President Obama confronting three senators opposing the plan.[524]
The show aired another sketch in September 2013 with Jay Pharoah as President Obama rolling out the plan to the public, and Aaron Paul and other cast members playing ordinary Americans helping him in advocating for the legislation.[525]
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^Alonso-Zaldivar, Ricardo (July 31, 2014). "Probe exposes flaws behind HealthCare.gov rollout". AP News. Archived from the original on August 8, 2014. Retrieved July 31, 2014.
^Tracer, Zachary (June 2, 2015). "Obamacare Sign-Ups Decline to 10.2 Million as Some Don't Pay". Bloomberg.com. Retrieved August 21, 2016.
^"December 31, 2015 Effectuated Enrollment Snapshot". cms.gov. Baltimore, MD: Health and Human Services. March 11, 2016. Archived from the original on April 11, 2016. Retrieved June 18, 2022.
^COOK, NANCY (December 16, 2015). "How the White House lost on the Cadillac Tax". Politico. Retrieved August 21, 2016.
^Mathews, Anna Wilde (August 16, 2016). "Aetna to Drop Some Affordable Care Act Markets". The Wall Street Journal. News Corp. ISSN 0099-9660. OCLC 781541372. Retrieved August 16, 2016.
^Ip, Greg (August 17, 2016). "The Unstable Economics in Obama's Health Law". The Wall Street Journal. ISSN 0099-9660. Retrieved August 23, 2016.
^ a bPear, Robert (February 3, 2017). "Affordable Care Act signups dip amid uncertainty and Trump attacks". The New York Times. ISSN 0362-4331. OCLC 1645522. Archived from the original on February 5, 2017. Retrieved June 18, 2022.
^Morton, Victor (February 14, 2017). "IRS weakens enforcement of Obamacare individual mandate: Report". The Washington Times. Retrieved February 16, 2017.
^"House Passes Bill to Repeal Obamacare: Live Updates". The Wall Street Journal. News Corp. ISSN 1042-9840. OCLC 781541372. Retrieved May 5, 2017.
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^O'Brien, Elizabeth (December 2, 2017). "The Senate's Tax Bill Eliminates the Individual Mandate for Health Insurance. Here's What You Need to Know". Money. New York City. ISSN 0149-4953. Archived from the original on March 2, 2020.
^Kaplan, Thomas; Pear, Robert (October 17, 2017). "2 Senators Strike Deal on Health Subsidies That Trump Cut Off". The New York Times. ISSN 0362-4331. OCLC 1645522. Archived from the original on October 18, 2017. Retrieved June 18, 2022.
^"Where the states stand on Medicaid expansion". Daily Briefing. The Advisory Board. February 6, 2019. Archived from the original on November 20, 2013. Retrieved June 18, 2022.
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Further reading
Barr, Donald A. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. JHU Press. ISBN 978-1-4214-0218-5.
Bossaler, Jenny S. (April 2016). "Access to affordable care through public libraries". The Library Quarterly. 86 (2). University of Chicago Press: 193–212. doi:10.1086/685400. ISSN 0024-2519. JSTOR 26561661. OCLC 01755858. S2CID 147627006.
CCH's Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact. Chicago, IL: Wolters Kluwer Law & Business. 2010. ISBN 978-0-8080-2287-9. Two volumes: This book contains an editorially enhanced version of the Patient Protection and Affordable Care Act that integrates in place changes made to it by the Reconciliation Act of 2010. ... A website, www.mediregs.com/cchhealthreform, has been created to expand access to key legislative materials.
Fang, Hanming; Krueger, Dirk (2022). "The Affordable Care Act After a Decade: Its Impact on the Labor Market and the Macro Economy". Annual Review of Economics. 14 (1). Cambridge MA: National Bureau of Economic Research. doi:10.3386/w29240. ISSN 1941-1391. LCCN 2008214322. OCLC 190859329.
Feldman, Arthur M. (2012) [2011]. Understanding Health Care Reform: Bridging the Gap Between Myth and Reality. CRC Press. ISBN 978-1-4398-7948-1. Archived from the original on June 16, 2022.
Jacobs, Lawrence R.; Skocpol, Theda (2010). Health Care Reform and American Politics. Oxford University Press. ISBN 978-0-19-978142-3.
McDonough, John E. (August 2, 2011). Inside National Health Reform. University of California Press. ISBN 978-0-520-27019-0.
Brill, Steven (January 5, 2015). America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. Random House. ISBN 978-0-8129-9695-1.
"Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act". United States. Congressional Budget Office. July 24, 2012. Archived from the original (Cost estimate) on July 27, 2012. Retrieved July 27, 2012.
Elmendorf, Douglas W. (November 30, 2009). "An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act" (PDF). United States. Congressional Budget Office. Archived from the original on December 5, 2009. Retrieved June 29, 2012.
"Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010". United States. Congressional Budget Office. May 26, 2011. Archived from the original on March 3, 2012. Retrieved April 1, 2012.
Glied, Sherry; Ma, Stephanie (December 2013). "How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion" (PDF). Issue Brief. 32. The Commonwealth Fund: 1–12. PMID 24344468. Retrieved February 20, 2016.
Jost, Timothy (February 24, 2014). "Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act". Health Affairs. Washington, DC: Project HOPE. doi:10.1377/forefront.20140224.037390. ISSN 1544-5208. OCLC 07760874.
Riley, Trish; Thorpe, Jane Hyatt (2012). "Multi-state plans under the Affordable Care Act" (PDF). Department of Health Policy. The George Washington University: School of Public Health and Health Services. Archived from the original (PDF) on June 26, 2013.
"Following The Affordable Care Act". Health Affairs. ISSN 1544-5208. OCLC 07760874. Retrieved August 10, 2019.
"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)". Archived from the original on April 29, 2011. Retrieved April 29, 2011.
Mettler, Suzanne (2011). The Submerged State: How Invisible Government Policies Undermine American Democracy. University of Chicago Press. ISBN 9780226521664. OCLC 928901062.
Mettler, Suzanne (April 17, 2012). "The Submerged State". Office Hours podcast. Society Pages. Identifier 1000365943260
Jacobs, Lawrence R.; Mettler, Suzanne (2020). "What Health Reform Tells Us about American Politics". Journal of Health Politics, Policy and Law. 45 (4): 581–593. doi:10.1215/03616878-8255505. ISSN 0361-6878. LCCN 76646971. OCLC 2115780. PMID 32186336. S2CID 212752729.
Preliminary CBO documents
Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment. United States. Congressional Budget Office December 19, 2009. (Cost estimate)
Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
Base Analysis—H.R. 3590, Patient Protection and Affordable Care Act, United States. Congressional Budget Office. November 18, 2009. (Cost estimate) (The additional and/or related CBO reporting that follows can be accessed from the above link)
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
Estimated Financial Effects of the "Patient Protection and Affordable Care Act", as Amended. April 22, 2010.
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
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.
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
Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN; also available from Finance.Senate.Gov (accessed April 1, 2012).
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Media from Commons
News from Wikinews
Texts from Wikisource