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Affordable Care Act

The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and colloquially as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965.[1][2][3][4]

"Obamacare" redirects here. For the song, see Obamacare (song).

Long title

An Act Entitled The Patient Protection and Affordable Care Act

ACA, PPACA

Obamacare, Affordable Care Act, Health Insurance Reform, Healthcare Reform

March 23, 2010 (2010-03-23)
Most major provisions phased in by January 2014; remaining provisions phased in by 2020; penalty enforcing individual mandate set at $0 starting 2019

124 Stat. 119 through 124 Stat. 1025 (906 pages)

The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered.[5][6] The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.[7]


The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to changes to individual insurance markets. Both received new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office (CBO) reports said that overall these provisions reduced the budget deficit, that repealing ACA would increase the deficit,[8][9] and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.[10]


The act largely retained the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled.[1][11] Insurers were made to accept all applicants without charging based on preexisting conditions or demographic status (except age). To combat the resultant adverse selection, the act mandated that individuals buy insurance (or pay a monetary penalty) and that insurers cover a list of "essential health benefits".


Before and after enactment the ACA faced strong political opposition, calls for repeal and legal challenges. In National Federation of Independent Business v. Sebelius, the Supreme Court ruled that states could choose not to participate in the law's Medicaid expansion, but upheld the law as a whole.[12] The federal health insurance exchange, HealthCare.gov, faced major technical problems at the beginning of its rollout in 2013. Polls initially found that a plurality of Americans opposed the act, although its individual provisions were generally more popular.[13] By 2017, the law had majority support.[14] The Tax Cuts and Jobs Act of 2017 set the individual mandate penalty at $0 starting in 2019.[15] This raised questions about whether the ACA was still constitutional.[16][17][18] In June 2021, the Supreme Court upheld the ACA for the third time in California v. Texas.[19]

prohibits insurers from denying coverage to individuals due to preexisting conditions.[22]

Guaranteed issue

States were required to ensure the availability of insurance for individual children who did not have coverage via their families.

A partial allows premiums to vary only by age and location, regardless of preexisting conditions. Premiums for older applicants can be no more than three times those for the youngest.[23]

community rating

must be provided. The National Academy of Medicine defines the law's "essential health benefits" as "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care"[24][25] and others[26] rated Level A or B[27] by the U.S. Preventive Services Task Force.[28] In determining essential benefits, the law required that standard benefits should offer at least that of a "typical employer plan".[29] States may require additional services.[30]

Essential health benefits

Preventive care and screenings for women. "[A]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity".[32] This mandate applies to all employers and educational institutions except for religious organizations.[33][34] These regulations were included on the recommendations of the Institute of Medicine.[35][36]

[31]

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.

[261]

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.[361] 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".[362][363]


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."[362]


By mid-2012, Obamacare had become the colloquial term used both by supporters and opponents.[361] Obama eventually endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."[364]

Lawsuits such as and House v. Price.

King v. Burwell

President Trump ended the payment of 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.[467] In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019.[413] 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.[468][469] 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.[470] 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.[413][471]

cost-sharing reduction

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 .[472] The cutoff generated some 50 lawsuits. The Supreme Court granted certiorari in 2019 in the case Maine Community Health Options v. United States.[473][474][475]

Marco Rubio

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.

[476]

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. The CBO said the reductions would reduce ACA enrollment.[467]

[477]

Trump reduced the enrollment period for 2018 by half, to 45 days.

[478]

Trump made public statements that the exchanges were unstable or in a .[479]

death spiral

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.[514]


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.[515]

Broccoli mandate

Comparison of the healthcare systems in Canada and the United States

Individual shared responsibility provision

(sometimes called "Romneycare")

Massachusetts health care reform

Medicaid

(Reform to the American Health Care system signed into law by President Obama)

Medicare Access and CHIP Reauthorization Act of 2015

Single-payer health care

Universal health care

Universal health coverage by country

U.S. with eight other countries (tabular form)

health care compared

Barr, Donald A. (2011). . JHU Press. ISBN 978-1-4214-0218-5.

Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America

Bossaler, Jenny S. (April 2016). "Access to affordable care through public libraries". The Library Quarterly. 86 (2). University of Chicago Press: 193–212. :10.1086/685400. ISSN 0024-2519. JSTOR 26561661. OCLC 01755858. S2CID 147627006.

doi

. 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.

CCH's Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact

Fang, Hanming; Krueger, Dirk (2022). . Annual Review of Economics. 14 (1). Cambridge MA: National Bureau of Economic Research. doi:10.3386/w29240. ISSN 1941-1391. LCCN 2008214322. OCLC 190859329.

"The Affordable Care Act After a Decade: Its Impact on the Labor Market and the Macro Economy"

Feldman, Arthur M. (2012) [2011]. . CRC Press. ISBN 978-1-4398-7948-1. Archived from the original on June 16, 2022.

Understanding Health Care Reform: Bridging the Gap Between Myth and Reality

Jacobs, Lawrence R.; Skocpol, Theda (2010). . Oxford University Press. ISBN 978-0-19-978142-3.

Health Care Reform and American Politics

McDonough, John E. (August 2, 2011). . University of California Press. ISBN 978-0-520-27019-0.

Inside National Health Reform

. United States. Congressional Budget Office. July 24, 2012. Archived from the original (Cost estimate) on July 27, 2012. Retrieved July 27, 2012.

"Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act"

Elmendorf, Douglas W. (November 30, 2009). (PDF). United States. Congressional Budget Office. Archived from the original on December 5, 2009. Retrieved June 29, 2012.

"An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act"

. United States. Congressional Budget Office. May 26, 2011. Archived from the original on March 3, 2012. Retrieved April 1, 2012.

"Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010"

; 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.

Glied, Sherry

Jost, Timothy (February 24, 2014). "Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act". . Washington, DC: Project HOPE. doi:10.1377/forefront.20140224.037390. ISSN 1544-5208. OCLC 07760874.

Health Affairs

Riley, Trish; Thorpe, Jane Hyatt (2012). (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.

"Multi-state plans under the Affordable Care Act"

. Health Affairs. ISSN 1544-5208. OCLC 07760874. Retrieved August 10, 2019.

"Following The Affordable Care Act"

. Archived from the original on April 29, 2011. Retrieved April 29, 2011.

"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)"

Mettler, Suzanne (2011). The Submerged State: How Invisible Government Policies Undermine American Democracy. University of Chicago Press.  9780226521664. OCLC 928901062.

ISBN

Mettler, Suzanne (April 17, 2012). . Office Hours podcast. Society Pages. Identifier 1000365943260

"The Submerged State"

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. :10.1215/03616878-8255505. ISSN 0361-6878. LCCN 76646971. OCLC 2115780. PMID 32186336. S2CID 212752729.

doi

as amended (PDF/details) in the GPO Statute Compilations collection

Patient Protection and Affordable Care Act

via Democratic Policy Committee (Senate.gov)

Full text, summary, background, provisions and more