Patient Protection and Affordable Care Act , often shortened to the Affordable Care Act ( ACA ) or dubbed Obamacare , is a United States federal law passed by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. The term "Obamacare" was first used by opponents, then used by supporters, and eventually used by President Obama himself.. Together with the Healthcare and Education Reconciliation Act in 2010, this is an improvement in the regulation and improvement of the most important coverage of the US health care system since the passage of Medicare and Medicaid in 1965.
The main provisions of the ACA come into force in 2014. By 2016, the uninsured portion of the population has approximately half, with estimates ranging from 20-24 million additional people during 2016. Increased coverage is due, more or less, to the extension of Medicaid Eligibility and major changes to the individual insurance market. Both involve new expenses, which are funded through a combination of taxes and new deductions for Medicare and Medicare Advantage tariff providers. Some reports of the Congressional Budget Office say that this entire provision reduces the budget deficit, which cancels the ACA will increase the deficit, and that the legislation reduces income inequality by imposing a tax primarily on the 1% to fund about $ 600 of average benefits for families under 40 % of income distribution. The law also implements a number of shipping system reforms that are intended to limit health care costs and improve quality. Once the law comes into effect, overall health care spending increases slow, including premiums for employer-based insurance plans.
This law largely retains the existing Medicare, Medicaid, and employer market structures, but individual markets are radically reformed around a three foot scheme. Insurers in this market are made to accept all applicants and charge the same rate regardless of pre-existing conditions or sex. To combat the resulting adverse selection, legislation mandates that individuals purchase insurance and insurance includes a list of "essential health benefits". However, the withdrawal of the tax mandate, passed as part of the Withholding Tax and the Employment Act of 2017, will become effective by 2019. To assist households between 100-400% of the Federal Poverty Line pay this compulsory policy, the law provides for insurance premium subsidies. Other individual market changes include health markets and risk adjustment programs.
It also faces challenges and disagreements. The Supreme Court ruled 5 to 4 in 2012 that the state may choose not to participate in the ACA Medicaid expansion, even though it upholds the law as a whole. The federal healthcare trade, HealthCare.gov, faces major technical issues at the start of its launch in 2013. By 2017, the unified Republican government has failed to pass several different parallels from the ACA. The law spends several years opposed by a small number of Americans surveyed, although its provisions are generally more popular than the law as a whole, and the law enjoys majority support by 2017.
Video Patient Protection and Affordable Care Act
Terms
An individual's mandate is a requirement to buy insurance or pay a fine for anyone not covered by an employer-sponsored health plan, Medicaid, Medicare or other public insurance program (such as Tricare). Also excluded are those who face financial difficulties or who are members of a recognized religious sect excluded by the Internal Revenue Service.
Mandates and open registration limits are designed to avoid the death of spiral insurance where healthy people delay insuring themselves until they are sick. In situations like this, insurance companies should raise their premiums to cover a relatively more painful and more expensive policy, which could create a vicious cycle where more people are leaving their reach.
The purpose of this mandate is to prevent the health system from giving up on adverse selection, which will result in a high premium for insured coverage and less (and thus more medical illness and bankruptcy) for the uninsured. Studies by CBO, Gruber and Rand Health conclude that mandates are required. The mandate increases the size and diversity of the insured population, including younger and healthier participants to expand risk groups, spreading costs. Experience in New Jersey and Massachusetts offers different results.
Among the groups that are not subject to the individual's mandate are:
- Illegal immigrants, estimated at about 8 million - or about a third of 23 million projections - are not eligible for insurance subsidies and Medicaid. They remain eligible for emergency services.
- Eligible people are not registered with Medicaid.
- Citizens who pay an annual fine rather than buy insurance, mostly younger and single.
- Citizens whose insurance coverage will cost more than 8% of household income and are exempt from penalties.
- Citizens living in states that opt ​​out of Medicaid expansion and who are eligible for no Medicaid coverage or subsidized coverage through new state insurance exchanges.
- All citizens begin December 20, 2017
On December 20, 2017, the individual's mandate is lifted starting in 2019 through the Withholding Tax and Jobs Act of 2017.
Subsidents
Households with incomes between 100% and 400% of federal poverty are eligible to receive federal subsidies for purchased policies through exchange. Subsidies are provided as refundable and refundable tax credits. In addition, small businesses qualify for tax credits provided they register in the SHOP Marketplace. By law, workers whose employers offer affordable coverage will not be eligible for subsidies through the exchange. To be eligible, employer-based health insurance costs must exceed 9.5% of the worker's household income.
Exchange
Established the creation of health insurance exchanges in all fifty states. The regulated exchange, most of the online marketplace, is managed by the federal or state government, where individuals and small businesses can purchase personal insurance plans.
Setting up the exchange gives the wisdom of some countries on insurance standards and prices. For example, the state approves the sales plan, and the effect (through limits and negotiations with private insurance companies) the price offered. They may impose higher or country-specific coverage requirements - including whether plans offered in the state may include abortion. Country without exchange does not have that wisdom. Responsibility for operating their exchange moves to the federal government.
The risk corridor program
The risk corridor program is a temporary risk management tool defined under the section of PPACA 1342 to encourage insurance companies to be reluctant to enter the "new and untested" ACA insurance market during the first three years of the ACA implemented (2014-2016). For those years, the Department of Health and Human Services (HHS) "will bear some of the losses for insurers whose plans are performing worse than they expect to be." The highly profitable insurers, on their part, must return to HHS part of their money. they get on the stock "
According to an article in Forbes, the risk corridor has been a successful part of the Medicare prescription drug benefit, and the risk corridor of ACA is modeled after Medicare's Plan D. " They implemented the principle that "more participation will mean more competition, which will lower premiums and make health insurance more affordable" and "insurance companies that register to sell health plans on the exchange, they do so in the hope that risk corridor programs will limit their losses. "The risk corridor managed to attract the ACA insurance company. The program does not pay for itself as planned with "accumulated losses" of up to $ 8.3 billion for 2014 and 2015 alone. Authorizations must be awarded for HHS to pay insurance from "general government revenue". The Republican Congress "denounces" the program as a 'bailout' for insurance companies. Then-Rep. Jack Kingston (R-Ga.), At the Allocation Committee funding the Department of Health and Human Services and the Department of Labor "[slip] in a sentence" - Section 227 - in "massive" allocation of the Consolidated Appropriations Act 2014 HR 3547) which says that no funds in the discretionary expenditure bill "can be used for corridor-risk payments." This effectively "blocks administration from obtaining necessary funds from other programs" and puts Congress in potential breach of contract with insurance that offers eligible health plans, under the Tucker Act for not paying for insurance.
On February 10, 2017, at Moda Health v. The US Government, Moda, one of the insurance companies that struggled financially for the abolition of the risk corridor program, won a "$ 214-million assessment of the federal government". On appeal, judge Thomas C. Wheeler stated, "The government made a promise in the unfulfilled risk corridor program Today, the court directs the Government to fulfill that promise, and again, to say to [Moda]," The joke is on you. You should not believe us, "it's hardly worth it for our great government."
Temporary reinsurance
Temporary reinsurance for insurance against unexpected claims is a program that runs from 2014 to 2016. It is intended to limit insurance losses.
Risk adjustment
Of the three risk management programs, only permanent risk adjustment. Risk adjustments seek to spread risk among insurance companies to prevent buyers with good knowledge of their medical needs from using insurance to cover their costs (reverse selection). A plan with a low actuarial compensation plan with high actuarial risk.
Medicaid Expansion
The ACA revises and expands Medicaid requirements starting 2014. Under the written law, all US citizens and legal residents with incomes of up to 133% of the poverty line, including adults without dependent children, will qualify for coverage in the state whichever participates in the Medicaid Program. The federal government pays 100% of Medicaid eligibility expansion fees in participating countries by 2014, 2015 and 2016; and will pay 95% by 2017, 94% by 2018, 93% by 2019, and 90% by 2020 and all the following year. The law provides 5% "revenue waiver", making effective income earning limits for Medicaid 138% of poverty levels.
However, the Supreme Court ruled in NFIB v. Sebelius that the ACA provisions are coercive, and that the federal government should allow countries to proceed at the pre-ACA funding and feasibility levels if they vote.
Medicare Savings
Reduced expenses include reductions of Medicare reimbursements to insurance companies and drug companies for private Medicare Advantage policies by the Government Accountability Office and Medicare Advisory Advisory Commission found to be too expensive compared to government Medicare; and substitution of Medicare replacement to hospitals that failed standard of efficiency and care.
Tax
Medicare tax
Income from entrepreneurial and single individual wages exceeding $ 200,000 per annum is subject to an additional tax of 0.9%. The threshold amount is $ 250,000 for married couples applying jointly (the threshold applies for combined compensation of two pairs), or $ 125,000 for married people who file separately.
In the ACA companion law, the Health and Education Reconciliation Act of 2010, the additional Medicare tax of 3.8% applied to unbilled earnings, in particular a smaller net investment income or an amount adjusted for gross revenue exceeding $ 200,000 ( $ 250,000 for married couples filed, $ 125,000 for married people who filed separately.)
Excise tax
Excise tax for the Affordable Care Act raised $ 16.3 billion in fiscal 2015 (17% of all excise taxes collected by the Federal Government). $ 11.3 billion is raised by excise taxes placed directly on health insurance based on their market share. The ACA also includes excise taxes of 40% ("Cadillac tax") on total corporate premium expenses exceeding the specified dollar amount ($ 10,200 for single coverage and $ 27,500 for family coverage) indexed into inflation, originally scheduled to take effect in 2018 , but pending until 2020 by the Consolidated Allocation Act, 2016. The annual excise tax of $ 3 billion is imposed on importers and prescription drug manufacturers. Excise tax of 2.3% on medical equipment and 10% excise on indoor tanning service is also applied.
SCHIP
The registration process of State Child Health Insurance (CHIP) is simplified.
Deposit Health Insurance
Dependents are allowed to remain in their parent's insurance plan until their 26th birthday, including dependents who no longer live with their parents, are not dependent on parental taxes, are no longer students, or are married.
Company mandate
Businesses that employ 50 or more people but do not offer health insurance to full-time employees pay tax penalties if the government subsidizes full-time employee health through tax deductions or other means. This is commonly known as the employer's mandate. This provision is included to encourage entrepreneurs to continue providing insurance once the stock starts to operate. Approximately 44% of the population is covered directly or indirectly through employers.
Delivery system reform
The law includes a number of shipping system reforms that are intended to limit health care costs and improve quality. This includes changes to Medicare payments to prevent hospital conditions and readmissions obtained, bundled payment initiatives, Medicare Center and Medicaid Innovation, the Independent Advisory Board, and the establishment of a responsible care organization.
Hospital quality
Cost/quality health care initiatives include incentives to reduce hospital infections, to adopt electronic medical records, and to coordinate care and prioritize quality over quantity.
The Hospital Immunization Reduction Program (HRPP) was established in addition to the Social Security Act, in an effort to reduce hospital readings. This program punishes hospitals with a higher rate of return than expected by reducing their Medicare replacement rate.
Bundled Payments
The Medicare payment system shifts from cost-for-service to bundled payments. Single payments must be paid to hospitals and groups of doctors for prescribed care episodes (such as hip replacements) rather than individual payments to individual service providers. In addition, the Medicare Part D coverage gap (commonly called "donut hole") shrank gradually, closing completely on January 1, 2020.
Organization of Accountable Care
The law allows the creation of Accountable Care Organizations (ACOs), a group of doctors, hospitals and other providers committed to providing high quality, coordinated care to Medicare patients. ACO is allowed to continue to use fees for the service billing approach. They receive government bonus payouts to minimize costs while achieving quality benchmarks that emphasize the prevention and mitigation of chronic diseases. If they fail to do so, they are subject to punishment.
Unlike the Health Care Organization, ACO patients are not required to obtain all treatment from ACO. Also, unlike HMO, ACO must achieve quality care objectives.
Medicare donut hole
Participants of Medicare Part D receive a 50% discount on branded drugs purchased after exhausting their initial coverage and before reaching the catastrophic threshold. The US Department of Health and Human Services began sending rebate checks in 2010. By 2020, donut holes will be completely removed.
Country liberation
From 2017 onwards, countries can submit "liberation for state innovation" that allows them to conduct experiments that meet certain criteria. To gain exemption, the state must pass a law establishing an alternative health system that provides at least as comprehensive and affordable insurance as ACA, covering at least as many residents as possible and not increasing the federal deficit. These countries may be exempt from some ACA requirements, including individual and employer mandates and insurance exchange terms. The state will receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which the inhabitants and employers will qualify under the ACA plan, if they can not be paid under the state plan.
In May 2011, Vermont enacted Green Mountain Care, a nation-wide sole payer system in which they intended to pursue a waiver to apply. In December 2014, Vermont decided not to continue because of the high expected costs.
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- The Community Life Assistance and Support Service (CLASS Act) forms the choice of long-term, voluntary and general care insurance for employees,
- The Operated and Consumer-Oriented Package (CO-OP), a member-managed non-profit insurance company, can start providing health insurance, based on a 5-year federal loan.
Maps Patient Protection and Affordable Care Act
Legislative history
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An individual mandate coupled with a subsidy for private insurance as a means for universal health care is considered the best way to win support from the Senate because it has been included in previous bipartisan reform proposals. This concept goes back to at least 1989, when the conservative The Heritage Foundation proposed an individual's mandate as an alternative to single payer health care. It is fought for a while by conservative economists and Republican senators as a market-based approach to health reform on the basis of individual responsibility and avoiding the problems of free riders. In particular, since 1986 Emergency Medical Treatment and Active Employment Act (EMTALA) requires that any hospital participating in Medicare (almost all) to provide emergency care to anyone who needs it, the government often indirectly covers the costs of those unable to pay.
President Bill Clinton proposed a health reform bill in 1993 that included a mandate for employers to provide health insurance for all employees through markets administered by health maintenance organizations. Senators of the Republic proposed an alternative that would require individuals, but not employers, to buy insurance. Eventually Clinton's plan failed in the midst of a series of negative ads that have never been funded by conservative political groups and the health insurance industry and because of fears that it was too complicated. Clinton negotiated a compromise with the 105th Congress to replace the State Children's Health Insurance Program (SCHIP) in 1997.
The 1993 Republican Alternative, introduced by Senator John Chafee as the Current Equity and Access to Health Reform Act, contains the terms "universal coverage" with penalties for individual noncompliance - as well as subsidies to be used in the states. 'purchase groups'. Advocates for the 1993 bill included prominent Republicans such as Senator Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond. Of the 43 Republican Senators in 1993, 20 supported the HEART Act. Another Republican proposal, introduced in 1994 by Sen. Don Nickles (R-OK), the Consumer Choice Health Security Act, contains the mandate of individuals with penal provisions; However, Nickles later removed the mandate from the bill, stating he had decided "that the government should not force people to buy health insurance". At the time of this proposal, the Republic did not raise a constitutional issue with a mandate; Mark Pauly, who helped develop a proposal that included the individual's mandate for George HW Bush, commented, "I do not recall that being raised at all, the way it was seen by the Congressional Budget Office in 1994, effectively, as a tax."
In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contains individual mandates and insurance exchanges. Republican Governor Mitt Romney vetoed the mandate, but after the Democrats overruled the veto, he signed it into law. Romney's execution of the 'Health Connector' exchanges and individual mandates in Massachusetts was initially praised by Republicans. During the 2008 presidential campaign of Romney, Sen. Jim DeMint praised Romney's ability to "take some good conservative ideas, such as private health insurance, and apply them to the need to have everyone insured". Romney said of the individual's mandate: "I am proud of what we have done, and if Massachusetts succeeds in implementing it, it will be a model for the nation."
In 2007, a year after the Massachusetts reform, Republican Sen. Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy American Law, which featured individual and state mandates, regulating the insurance market called "State Health Assistance Agency". The bill initially attracted bipartisan support, but died on committees. Many sponsors and sponsors remain in Congress during the 2008 health debate.
In 2008 many Democrats considered this approach as the basis for health care reform. Experts say that the legislation that finally emerged from Congress in 2009 and 2010 has similarities to the 2007 bill and that it was deliberately patterned after the state health plan Romney.
Debate on health care, 2008-10
Health reforms are a key topic during the 2008 Democratic presidential primaries. As the race narrows, attention is focused on plans proposed by the two main candidates, Hillary Clinton and the final candidate, Barack Obama. Each candidate proposes a plan to cover about 45 million Americans who are not expected to have health insurance at some point every year. Clinton's proposal would require all Americans to get coverage (essentially, individual mandates), while Obama's proposal subsidizes but rejects the use of an individual's mandate.
During the election, Obama said that improving health would be one of his top four priorities as president. Obama and his opponent, Senator John McCain, proposed health insurance reforms despite their very different. Senator John McCain proposed a tax credit for health insurance purchased on the individual market, which is estimated to reduce the number of uninsured persons by about 2 million by 2018. Obama proposes private and public group insurance, income-based subsidies, consumer protection, and expansion of Medicaid and SCHIP , estimated at the time to reduce the number of uninsured persons by 33.9 million by 2018.
After his inauguration, Obama announced to a joint session of Congress in February 2009 of his intention to work with Congress to build a plan for health care reform. In July, a series of bills were approved by committees within the House of Representatives. On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a health care reform bill. This group - in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe - met for over 60 hours, and the principles they discussed, along with other committees, of the Senate health reform bill.
Democratic Congresses and health policy experts such as MIT economics professor Jonathan Gruber and David Cutler argue that the issue is guaranteed to require both community ratings and individual mandates to ensure that adverse selection and/or "free ride" will not result in an insurance "spiral of death". This approach was taken because the president and congressional leaders have concluded that more progressive plans, such as the Medicare for All act, can not get support for evidence in the Senate. By deliberately exploiting bipartisan ideas - the same basic framework is supported by former majority Senate leader Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell - drafters of the bill hoping to collect the necessary votes for the part.
However, after the adoption of the individual mandate, the Republicans came to defy the mandate and threatened to file all bills that contained it. Senate minority leader Mitch McConnell, who led the Republican congress strategy in response to the bill, calculated that Republicans should not support the bill, and work to prevent defections:
It is important that everyone is united because if the supporters of the bill can say it bipartisan, it is inclined to convey to the public that this is okay, they must have known.
Republican senators, including those who supported the previous bill with similar mandates, began to describe the mandate as "unconstitutional". Journalist Ezra Klein wrote in The New Yorker that "a policy that once enjoyed widespread support within the Republican Party suddenly faces a united opposition." Reporter Michael Cooper of The New York Times wrote that: "the provision... requires all Americans to buy health insurance rooted in conservative thinking."
Reform negotiations also attracted lobbyists' attention, including agreement between certain lobby groups and legislators to win the support of groups opposed to past reforms, such as in 1993. The Sunlight Foundation documents many of the reported links between "health care "complex lobbyists" and politicians on both sides.
During the August 2009 summer congress recession, many members returned to their districts and held town hall meetings on the proposal. The newly born Tea Party movement organized protests and many conservative groups and individuals attended meetings to oppose the proposed reforms. Many threats were made against members of Congress during the debate.
When Congress returned from the recess, in September 2009 President Obama delivered a speech to a joint session of Congress in favor of the ongoing Congressional negotiations. He acknowledged the polarization of the debate, and quoted a letter from the late Sen. Edward "Ted" Kennedy who urged reform: "what we face above all is a moral issue: that is at stake not only the details of the policy but the fundamental principles of social justice and character our country. "On November 7, the House of Representatives passed the Affordable Health Care Act for America in a 220-215 vote and forwarded it to the Senate for ratification.
Senate
The Senate began working on its own proposal while the House was still working. The US Constitution requires all income-related charges to come from the House of Representatives. To formally comply with these requirements, the Senate uses HAP 3590, a bill on changes in housing taxes for service members. It has been endorsed by Parliament as a revenue-related modification to the Internal Revenue Code. The bill became a Senate vehicle for his health care reform proposal, discarding the original contents of the bill. The bill eventually incorporates elements of a proposal well reported by the Senate Health and Finance committee. With a Republican Senate minority swearing for the filibuster, 60 votes will be needed to pass the Senate. At the start of the 111th Congress, Democrats had only 58 votes; the Senate's seat in Minnesota was finally won by Al Franken still undergoing a recount, while Arlen Specter was still a Republican (he became a Democrat in April 2009).
Negotiations were made to satisfy moderate Democrats and bring Republican senators to ships; special attention was given to Republicans Bennett, Enzi, Grassley and Snowe. On July 7, Franken was sworn in, casting his 60th potential vote. On August 25 Ted Kennedy - an advocate of the old health care reform - died. Paul Kirk was appointed as temporary replacement for Senator Kennedy on September 24.
After a vote of the Financial Committee on October 15, the negotiations changed to moderate Democrats. The majority leader Harry Reid focuses on a satisfying centric. The power came to Joe Lieberman from Connecticut, an independent who met Democrats, and Nebraska Democrats Democrat Ben Nelson. Lieberman requested that the bill not include public options be met, although his supporters won various concessions, including allowing state-based public options such as Vermont's Green Mountain Care.
The White House and Reid conveyed Nelson's concerns during a 13-hour negotiation with two concessions: a compromise on abortion, modifying the language of the law "to grant the state the right to prohibit abortion coverage in their own exchange of insurance", which would require consumers to pay the procedure out of the pocket if the state decides thus; and amendments to offer higher Medicaid replacement rates for Nebraska. The final half of the compromise was mockingly called "Cornhusker Kickback" and was revoked in the bill of subsequent reconciliation amendments.
On December 23, the Senate voted 60-39 to end the debate on the bill: a klotil sound to end the filibuster. The bill was then passed, also 60-39, on 24 December 2009, with all Democrats and two independent voted for it, and all Republicans fight (except Jim Bunning, who did not vote). The bill is supported by AMA and AARP.
On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace Kennedy, having campaigned to give the Republican minority the 41st vote needed to defend the Republican philosophy. His victory became significant because of its effect on the legislative process. The first is psychological: the symbolic interest of losing the traditionally occupied Kennedy Massachusetts seat leaves many Democratic congressional members concerned about the political costs of passing the bill.
Home
Brown election means Democrats can no longer break the filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill; House Speaker Nancy Pelosi stepped down, ignoring Emanuel's reduced approach as "Kiddie Care".
Obama insisted on comprehensive reforms. The news that Anthem Blue Cross in California intends to raise premium rates for its patients by as much as 39% gives new evidence for reform. On February 22, he made a "Senate-inclined" proposal to consolidate the bill. He met with leaders of both parties on 25 February. The Democrats decided that the House would pass the Senate bill, to avoid any other Senate vote.
The Democratic House is expected to negotiate changes at the Senate House conference before passing the final bill. Since any bill that emerges from different conferences of the Senate bill must pass the Senate over other Republican filibuster, most of the Democratic House of Congress agrees to pass the Senate bill on condition that it be changed by the next bill. They drafted the Health Care and Education Reconciliation Act, which can be endorsed through a reconciliation process.
As per the 1974 Congressional Budget Act, reconciliation can not be subject to filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass the ACA in the first place; The bill has inherent non-budgetary rules. Although the approved Senate bill can not be ratified by reconciliation, most Democrats' demands are budget: "these changes - higher levels of subsidies, different types of taxes to pay them, nixing the Nebraska Medicaid deal - mainly involve taxes and expenses. in other words, they are exactly the type of policy that is suitable for reconciliation. "
The remaining obstacle is an important pro-life group of Democrats led by Bart Stupak who was initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to justify the opposition. The Senate bill does not include language that satisfies their concerns, but they can not handle abortion in the reconciliation bill because it is not budget. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. It won the support of Stupak and his group members and convinced the bills. The House of Representatives passed a Senate bill with a 219-212 vote on 21 March 2010, with 34 Democrats and all 178 Republicans voted against it. The next day, the Republican Party introduced a law to revoke the bill. Obama signed the ACA into law on March 23, 2010. Because of its part, the Republican Party has chosen to deprive all or part of the Affordable Care Act more than sixty times; no attempt by the Republicans to succeed. Amendment bill, Health Care and Education Reconciliation Act, House cleaning on 21 March; The Senate passed it on with reconciliation on March 25, and Obama signed it on March 30.
Impact
Coverage
The law has caused a significant reduction in the number and percentage of people who do not have health insurance. The CDC reports that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% over the period from January to June 2016. Uninsured rates are falling in every congressional district in the US between 2013 and 2015. The Congressional Budget Office reports on March 2016 that there are about 12 million people covered by the bursa (10 million of whom receive subsidies to help pay for insurance) and 11 million are eligible for Medicaid by law, a subtotal of 23 million people. The additional 1 million is covered by the ACA "Basic Health Program" with a total of 24 million. The CBO also estimates that ACA will reduce an uninsured net amount of 22 million by 2016, using slightly different calculations for the above figures with a total ACA coverage of 26 million, less than 4 million for a reduction in "field-based coverage work "and" no-group and other coverage. "
The Department of Health and Human Services (HHS) estimates that 20.0 million adults (ages 18-64) obtain health coverage through ACA as of February 2016, an increase of 2.4 million during September 2015. HHS estimates that 20.0 million of these include: a) 17.7 million from the initial open registration in 2013-2016; and b) 2.3 million young adults aged 19-25 years who initially got insurance from 2010-2013, as they were allowed to stay on their parents' plans until the age of 26 years. Of the 20 million, an estimated 6.1 million are aged 19-25. Similarly, the Urban Institute issued a report in December 2016 which says that approximately 19.2 million elderly Americans have obtained health insurance coverage from 2010 to 2015. In March 2016, the CBO reported that there were about 27 million people without insurance by 2016, the numbers they expect will range from 26-28 million to 2026. The CBO also estimates that the percentage of the insured among all US residents will remain at 90% through that period, 92-93% except unauthorized immigrants.
Countries that expand Medicaid have 7.3% uninsured insurance rates on average in the first quarter of 2016, while those who do not expand Medicaid have an insecure rate of 14.1%, among adults aged 18 to 64. By December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states did not.
By 2017, almost 70% of those on the exchange can buy insurance for less than $ 75/month after subsidies, which rose to offset a significant pre-subsidized price increase in the currency market. The increase in the cost of health care premiums in the employer market remains moderate. For example, health premiums for those borne by employers rose by 69% from 2000-2005, but only 27% from 2010 to 2015, with only a 3% increase from 2015 to 2016.
The ACA also helps reduce income inequality as measured after taxes, because taxes are higher than 5% of revenue earners and both subsidies and Medicaid expansions for low-income people. The CBO estimates that subsidies paid under the law in 2016 averaged $ 4,240 per person for the 10 million people who receive them, approximately $ 42 billion. For scale, subsidies for the employer's market, in the form of exemption from taxes paid by health insurance premiums on behalf of employees by employers, are approximately $ 1,700 per person by 2016, or a total of $ 266 billion in the employer's market. Employer market subsidies are not changed by law.
Insurance exchange
As of August 2016, 15 countries operate their own bourses. Other countries either use federal exchange, or are operated in partnership with or supported by the federal government.
Medicaid Expansion
By December 2016 there were 32 countries (including Washington DC) that had adopted the Medicaid extension, while 19 states did not. Countries that expand Medicaid have 7.3% uninsured insurance rates on average in the first quarter of 2016, while those who do not expand Medicaid have an insecure rate of 14.1%, among people adults aged 18 to 64. Following a Supreme Court ruling in 2012, stating that states will not lose Medicaid funds if they do not expand Medicaid under the ACA, some countries refuse to extend Medicaid coverage. More than half of the nation's uninsured population lives in these countries. In a report to Congress, the Medicare and Medicaid Service Center (CMS) estimates that the cost of expansion is $ 6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 million to 10 million people have received Medicaid coverage, mostly low-income adults. The Kaiser Family Foundation estimates in October 2015 that an additional 3.1 million people are not covered because of countries that reject Medicaid expansion.
Countries that resist Medicaid expansion can maintain their Medicaid requirements threshold, which in many countries is significantly below 133% of the poverty line. Many countries do not make Medicaid available to adults without children at any income level. Since subsidies on an exchange insurance plan are not available to those who are below the poverty line, such individuals have no new options. For example, in Kansas, where only able-bodied adults with children and with incomes under 32% of the eligible poverty line for Medicaid, those with incomes from 32% to 100% of poverty ($ 6,250 to $ 19,530 for a family of three) are not eligible for both Medicaid and federal subsidies to buy insurance. Absent children, well-grown adults are not eligible for Medicaid in Kansas.
The study of the impact of the country's decision to reject the expansion of Medicaid calculated that up to 6.4 million people could fall into this status. The federal government initially pays 100% of the expansion (until 2016). Subsidies are tapered to 90% by 2020 and continue to shrink thereafter. Some countries argue that they can not pay their 10% contribution. Studies show that refusing expansion will cost more than expanding Medicaid due to increased spending on emergency care without compensation expressed in part to be paid by Medicaid coverage,
A 2016 study led by Harvard University health economics professor Benjamin Sommers found that Kentucky and Arkansas residents, who both received Medicaid expansions, were more likely to receive health care services and were less likely to pay for emergency room expenses or had trouble paying bills medical. from before the expansion. Texans, who did not receive Medicaid expansions, did not see a similar improvement over the same period. Kentucky chose improved managed care, while Arkansas subsidized private insurance. The new Arkansas and Kentucky Governors have proposed reducing or modifying their programs. Between 2013 and 2015, uninsured rates fell from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared to 39% to 32% in Texas. Special improvements include primary and preventive care, fewer emergency room visits, reported high quality care, improved health, increased drug accessibility, reduced out-of-pocket expenses and increased outpatient visits, increased diabetes screening, glucose testing among patients diabetes and routine care. for chronic conditions.
A 2016 DHHS study found that countries that expand Medicaid have lower premiums on exchange policies, because they have fewer low-income registries, whose average health is worse than those who earn more.
Health insurance costs
The Act is designed to pay subsidies in the form of tax credits to individuals or families who buy insurance, based on income levels. High-income consumers receive lower subsidies. While pre-subsidized prices rose considerably from 2016 to 2017, so did subsidies, to reduce after-subsidized costs to consumers. For example, a study published in 2016 found that the average increase in premiums demanded in 2017 among non-smokers aged 40 years was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed a 40 percent increase in Alabama. and 60 percent in Texas. However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reports that for the second lowest cost of "Silver Plan" (a plan that is often selected and used as a benchmark for determining financial aid), a 40-year-old smoker who earns $ 30,000 per year will pay effectively the same amount in 2017 as happened in 2016 (about $ 208/month) after subsidies/tax credits, despite a substantial increase in pre-subsidized prices. This is nationally consistent. In other words, the subsidy increases along with the pre-subsidized price, fully offsetting the price increase.
Increasing the cost of health care premiums in employer markets continues to be moderate after the adoption of the law. For example, health premiums for those covered by employers increased by 69% from 2000-2005, but only 27% from 2010 to 2015, with only 3% increase from 2015 to 2016. From 2008-2010 (before ACA's share) insurance premium health rises an average of 10% per year.
Some studies have found that the financial crisis and the accompanying recession can not explain the overall slowdown and that structural changes are likely to share at least some of the credit. A 2013 study estimated that changes in the health system had caused about a quarter of the recent inflationary decline. Paul Krawzak states that while cost control has managed to reduce the amount spent on health care, such efforts alone may not be sufficient to address the long-term burden placed by demographic changes, especially population growth in Medicare.
In an ACA 2016 review published in JAMA , Barack Obama himself wrote that from 2010 to 2014 the average annual growth in spending per Medicare real-time spending was negative, down from an average of 4.7% per annum from 2000 to 2005 and 2.4% per annum from 2006 to 2010; likewise, real real per-enrollee growth in private insurance spending was 1.1% per annum during the period, compared with an average of 6.5% from 2000 to 2005 and 3.4% from 2005 to 2010.
Effects on deductibles and shared payments
While the cost of health insurance premiums has been moderated, some of these are due to higher-deductible insurance policies, maximum joint and out-of-pocket payments that shift the cost of insurance to patients. In addition, many employees choose to combine health savings accounts with higher abatement plans, making the impact of the ACA difficult to determine precisely.
For those who get insurance through their employer ("market group"), a survey of 2016 found that:
- Deductibles grew by 63% from 2011 to 2016, while premiums increased by 19% and employee income increased by 11%.
- By 2016, 4 out of 5 workers have a deductible insurance, which averages $ 1,478. For companies with fewer than 200 employees, an average reduction of $ 2,069.
- The percentage of workers with a reduction of at least $ 1,000 grew from 10% in 2006 to 51% by 2016. The 2016 figure fell to 38% after taking into account the contribution of the employer.
For "non-group" markets, two-thirds protected by the ACA market, a 2015 data survey found that:
- 49% have individual deductions of at least $ 1,500 ($ 3,000 for families), up from 36% in 2014.
- Many registrants in the market are eligible for a cost-sharing subsidy that reduces its net deductions.
- While about 75% of applicants are "very satisfied" or "somewhat satisfied" with their doctors and hospitals, only 50% have satisfaction with their annual deductions.
- While 52% of those covered by the ACA exchanges feel "well protected" by their insurers, in the group market, 63% feel that way.
Health results
Insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA is likely to prevent about 50,000 preventable patient deaths from 2010 to 2013. City Healthcare professors David Himmelstein and Steffie Woolhandler wrote in January 2017 that the decline of the ACA Medicaid expansion alone would cause around 43,956 deaths annually.
The Federal Reserve publishes data on early death rates by region, defined as those who died under the age of 74. According to the Kaiser Foundation, expanding Medicaid in the remaining 19 states will cover up to 4.5 million people. Because expanding Medicaid extends coverage and widens the scope of reducing mortality, therefore expanding Medicaid reduces death by syllogism. Texas, Oklahoma, Mississippi, Alabama, Georgia, Tennessee, Missouri, and South Carolina, are indicated on the map on the right as having many districts with high rates of premature death can reduce death by expanding Medicaid, other similar things.
Distribution impact
In March 2018, the CBO reported that the ACA has reduced the income inequality in 2014, saying that legislation leads the lowest and second quintiles (40% below) to receive an additional averages of $ 690 and $ 560 respectively ladder above 1% to pay an additional $ 21,000 due in large part to the net investment income tax and additional Medicare taxes. The law places relatively little burden on households in the top quintile (the top 20%) outside the top 1%.
Federal Deficit
estimated CBO earnings and impact on deficit
The CBO reported in several studies that the ACA would reduce the deficit, and that canceling it would increase the deficit. The comprehensive CBO estimate 2011 projected a net deficit reduction of more than $ 200 billion during the period 2012-2021: it calculates the law will generate $ 604 billion in total expenditure offset by $ 813 billion in total revenues, resulting in a net deficit reduction of $ 210 billion. The CBO separately predicts that although most of the spending provisions do not begin until 2014, revenues will outweigh spending in subsequent years. The CBO claims that the bill will "substantially reduce growth rates of Medicare payments for most services, impose excise taxes on insurance plans at relatively high premiums, and make other changes to the federal tax code, Medicare, Medicaid, and other programs." - extend the solvency extension of the Medicare trust fund for 8 years.
This estimate was made before the Supreme Court's decision allowing countries to opt out of Medicaid's expansion, thereby not proceeding with federal funding. CBO and JCT then renew budget projections, estimating the impact of the ruling will reduce the estimated cost of the $ 84 billion insurance protection provision.
CBO in June 2015 estimates that lifting the ACA will increase the deficit between $ 137 billion and $ 353 billion over the period 2016-2025, depending on the impact of the macroeconomic feedback effect. The CBO also estimates that lifting the ACA will likely lead to an average GDP increase of 0.7% in the period of 2021 to 2015, primarily by increasing labor supply.
Although CBOs generally do not provide cost estimates beyond the 10-year budget projection period due to the degree of uncertainty involved in projections, it decides to do so in this case at the request of the MPs, and estimates a second-decade deficit reduction of $ 1.2 trillion. The CBO estimates a deficit reduction of approximately a half-percentage point of GDP during the 2020s while warning that "various changes could occur".
Opinion on CBO projection
CBO cost estimates are criticized as they exclude the effects of potential legislation that would increase Medicare payments by more than $ 200 billion from 2010 to 2019. However, so-called "document improvements" are separate issues that will exist whether or not ACA becomes legal - eliminating the costs of the ACA is no different from eliminating other tax withholding charges.
Uwe Reinhardt, Princeton's health economist, writes. "The rigid and artificial rules in which the Congressional Budget Office should print the proposed law are unfortunately unable to produce the best unbiased estimate of possible fiscal impact of any law", but then say "But even if the budget office is mistaken in error significant in its conclusion that the bill will actually help reduce future federal deficits, I doubt that the financing of this bill will be approached as fiscally irresponsible as the financing of the Medicare Modernization Act of 2003. "Douglas Holtz-Eakin, director of CBO for the administration of George W. Bush, who later served as a key economic policy advisor to Senator John McCain's 2008 presidential campaign, alleged that the bill would raise a $ 562 billion deficit because, he argues, it's front-loaded revenues and back-loaded benefits.
Scheiber and Cohn rejected critical judgments of the impact of the law deficit, arguing that biased predictions against underestimating deficit reductions. They note that for example, it is easier to account for the cost of a certain subsidized rate for the number of persons prescribed than the savings account of preventive health care, and that the CBO has an overestimated cost track record and undermines the savings of health legislation; states, "Innovations in the delivery of medical care, such as the use of electronic medical records and greater financial incentives for more coordination of care among doctors, will result in substantial savings while also slowing down the incessant medical expense... But CBO would not consider the savings in their calculations, because innovation has not really been tried on a grand scale or in concert with each other - and that means there is not much data that is difficult to prove the savings will come true. "
In 2010, David Walker, former US Treasury then working for The Peter G. Peterson Foundation, stated that CBO estimates may not be accurate, because they are based on the assumption that the law will not change. The Center on Budget and Priority Policy objections that Congress has a good record of applying Medicare savings. According to their research, Congress follows through the application of most provisions enacted in the last 20 years to generate Medicare savings, even though no reduction in payments is handled by an "annual document repair".
Economic consequences
It is anticipated that CBOs in June 2015 that cancel the ACA will:
- Reduce aggregate demand (GDP) in the short run, because low-income people who tend to spend most of their additional resources will have fewer resources (eg, subsidized ACAs will be abolished). This effect will be offset in the long run by the labor supply factor below.
- Increase labor supply and aggregate compensation by about 0.8 and 0.9 percent over the period 2021-2025. The CBO cites the expanded ACA feasibility for Medicaid and subsidies and tax credits that go up with income as a disincentive to work, so canceling the ACA will eliminate such disincentives, encouraging workers to provide more hours.
- Increase the total number of working hours by about 1.5% over the period 2021-2025.
- Remove tax rates higher than capital income, thereby encouraging additional investments, increasing long-term capital and output stocks.
In 2015 the Center for Economic and Policy Research found no evidence that the company reduced working hours to avoid ACA requirements for employees who worked more than 30 hours per week.
CBO estimates that the ACA will reduce the number of labor force and number of working hours, as some are no longer tied to the employer for their insurance. Cohn, citing CBO projections, claims that the main job effects of the ACA are to reduce key jobs: "People who only work because they desperately need a corporate sponsored health insurance will no longer do it." He concludes that "the only significant impact of labor reform is the reduction of manpower, especially since people who hold jobs only to keep the insurance can eventually retire", because they have health insurance outside of their jobs.
Employer's mandate and part-time work
The employer's mandate requires that employers meet certain criteria to provide health insurance to their workers. The mandate applies to employers with more than 50 employees who do not offer health insurance to their full-time workers. Critics claim that mandates create unfavorable incentives for businesses to keep the number of permanent employees under 50 and to hire part-time workers instead. Between March 2010 and 2014 the number of part-time jobs decreased by 230,000, while the number of full-time jobs increased by 2 million. In the public sector, full-time employment turns into much more part-time employment than in the private sector. A 2016 study found only limited evidence that the ACA has increased its part-time job.
Some businesses and states of Virginia add a 29-hour cap a week to their part-time employees, to reflect a 30-hour-or-over definition for full-time workers. However, at the moment, only a few percent of companies have shifted their workforce to more part-time hours (4% in a survey of the Federal Reserve Bank of Minneapolis). Trends in working hours and the effects of the Great Recession are correlated with the pattern of part-time working hours. The impact of these provisions may have been offset by other factors, including that health insurance helps attract and retain employees, increase productivity and reduce absenteeism; and lower training and administrative costs of a smaller, full-time workforce of larger part-time workers. Relatively few companies employ more than 50 employees and over 90% of them offer insurance. Workers without an employer's insurance can buy insurance on the exchange.
Most policy analysts (both on the right and left) are critical of the mandate of the employer. They argue that the adverse incentive of part-time hours, even if they do not change the existing plan, is real and dangerous; that the increased marginal cost of the 50th worker for a business can limit the company's growth; that reporting and administration costs are not proportional to the cost of maintaining the company's plans; and notes that the employer's mandate is not important to maintain an adequate set of risks. The effect of these provisions results in vocal opposition from business interests and some unions are not granted exceptions.
A 2013/4 survey by the National Association for Business Economics found that about 75 percent of those polled said the ACA did not affect their planning or expectations for 2014, and 85 percent said the law would not encourage changes in their hiring practices. About 21 percent of the 64 businesses surveyed said that the action would have a harmful effect and 5 percent said it would be beneficial.
Hospital
From early 2010 to November 2014, 43 hospitals in rural areas were closed. Critics claim that the new law is causing the hospital to be closed. Many of these rural hospitals were built using funds from the 1946 Hill-Burton Act, to improve access to medical care in rural areas. Some of these hospitals are reopened as other medical facilities, but only a small number of emergency operating spaces (ERs) or urgent care centers.
Between January 2010 and 2015, a quarter of the emergency room doctors said they had seen a large increase in patients, while nearly half had a smaller increase. Seven out of ten ER doctors claim that they lack the resources to handle a large increase in the number of patients. The biggest factor in increasing the number of ER patients is inadequate primary care providers to handle more insured patients.
Insurers claim that because they have access and collect patient data allowing evaluation of interventions, they are critical to the success of ACO. Large insurance companies make their own ACO. Many hospitals are overwhelming
Source of the article : Wikipedia
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