Affordable Care Act

Patient Protection and Affordable Care Act

Long title	An act entitled The Patient Protection and Affordable Care Act.
Acronyms (colloquial)	PPACA
Nicknames	Health Care Reform
Enacted by	the 111th United States Congress
Effective	March 23, 2010
Citations
Public law	111-148
Statutes at Large	124 Stat. 119 thru 124 Stat. 1025 (906 pages)
Legislative history
Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009 Committee consideration by Ways and Means Passed the House on October 8, 2009 (416–0) Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39) with amendment House agreed to Senate amendment on March 21, 2010 (219–212) Signed into law by President Barack Obama on March 23, 2010
Major amendments
Health Care and Education Reconciliation Act of 2010

The Patient Protection and Affordable Care Act (PPACA) (Pub. L. 111–148 (text) (PDF), 124 Stat. 119, to be codified as amended at scattered sections of 42 U.S.C.) is a federal statute that was signed into law in the United States by President Barack Obama on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the Act is the product of the health care reform agenda of the Democratic 111th Congress and the Obama administration.

The law includes a large number of health-related provisions to take effect over the next four years, including expanding Medicaid eligibility, subsidizing insurance premiums, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage/claims based on pre-existing conditions, establishing health insurance exchanges, and support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies; there is also a tax penalty for citizens who do not obtain health insurance (unless they are exempt due to low income or other reasons). The Congressional Budget Office estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143 billion over the first decade. There was also a provision that buyers and sellers of gold would be subject to an additional tax on such items.

The Patient Protection and Affordable Care Act passed the Senate on December 24, 2009, by a vote of 60–39 with all Democrats and Independents voting for, and all Republicans voting against. It passed the House of Representatives on March 21, 2010, by a vote of 219–212, with all 178 Republicans and 34 Democrats voting against the bill. At the time of the vote, there were four vacancies in the House.

The bill was originally drafted by the Senate as an alternative to the Affordable Health Care for America Act, which was passed by the House two months earlier on November 7. However, after the Democrats lost their supermajority in the Senate on January 19, 2010 with the election of Scott Brown, the House decided to pass the Senate version and amend it with a third bill, the Health Care and Education Reconciliation Act of 2010. The Senate then passed a version of the third bill, amended to avoid application of the Byrd Rule, via the simple-majority reconciliation process. The amended third bill was then sent back to the House, where it passed. The President signed the reconciliation bill on March 30, 2010.

Legislative history

Background

Main articles: Health care reform in the United States, Health care reform debate in the United States, and Health care reforms proposed during the Obama administration

Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to go without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement.

During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his four priorities if he won the presidency. After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform. On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform and requested reform be enacted before the Congressional summer recess; but the reform was not passed by the requested date. In July 2009, a series of bills were approved by committees within the House of Representatives. A congressional recess followed in August, in which many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. During the summer recess, the Tea Party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.

In response to the opposition, Obama delivered a speech to a joint session of Congress on health reform supporting the reform and again outlining his proposals. On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.

The Senate bill, the Patient Protection and Affordable Care Act, bore similarities to a Republican healthcare reform proposal in 1993, the Health Equity and Access Reform Today Act of 1993; a 1994 Republican proposal under the Consumer Choice Health Security Act was similar in that it contained an individual mandate.

Senate

Senate vote by state.

  Two Democratic yeas

  One Democratic yea, one Republican nay

  One Republican nay, one Republican not voting

  Two Republican nays

House vote by congressional district.

  Democratic yea

  Democratic nay

  Republican nay

  No representative seated

President Barack Obama's signature on the bill.

The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.

Obama signing the bill at the White House

The Senate failed to take up debate on the House bill and instead took up H.R. 3590, a bill regarding housing tax breaks for service members. As the United States Constitution requires all revenue-related bills to originate in the House, the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill. The bill as amended incorporated elements of earlier proposals that had been reported favorably by the Senate Health and Finance committees.

Passage in the Senate was temporarily blocked by a filibuster threat by Nebraska Senator Ben Nelson, who sided with the Republican minority. Nelson's support for the bill was won after it was amended to offer a higher rate of Medicaid reimbursement for Nebraska. The compromise was derisively referred to as the "Cornhusker Kickback" (and was later repealed by the reconciliation bill). On December 23, the Senate voted 60–39 to end debate on the bill, eliminating the possibility of a filibuster by opponents. The bill then passed by a party-line vote of 60–39 on December 24, 2009, with one senator (Jim Bunning) not voting.

House

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate, giving the Republican minority enough votes to sustain a filibuster in the future. Following Brown's Senate win, the fate of the health care reform was uncertain. White House Chief of Staff Rahm Emanuel argued for a less ambitious bill, while House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care". Obama's siding with comprehensive reform and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument for reform. Obama unveiled a health care reform plan of his own, drawing largely from the Senate bill. On February 22 he laid out a "Senate-leaning" proposal to consolidate the bills. On February 25, he held a meeting with leaders of both parties urging passage of a reform bill. The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.

The most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and to instead pass the Senate's bill, and then pass amendments to it with a different bill allowing the Senate to pass the amendments via the reconciliation process.

Initially, there were not enough supporters to pass the bill requiring its proponents to negotiate with a group of pro-life Democrats, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion was substantive enough to cause their opposition to the bill. Instead of requesting inclusion of additional language specific to their abortion concerns in the bill, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. This concession won the support of Stupak and members of his group and assured passage of the bill.

The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. The following day, Republicans introduced legislation to repeal the bill. Obama signed the bill into law on March 23, 2010.

Provisions

H.R. 3590 is divided into 10 titles.

The bill contains provisions that will go into effect immediately; on June 21, 2010 (90 days after enactment); on September 23, 2010 (six months after enactment); and provisions that will go into effect in 2014. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.

Below are some of the key provisions of the bill:

Effective at enactment

• The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.
• The Medicaid drug rebate for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.
• Support comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute.
• Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.
• The Indian Health Care Improvement Act is reauthorized and amended.

Effective June 21, 2010

• Adults with pre-existing conditions will be eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014. To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months. There is no age requirement. The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allow premiums to vary by age (4:1), geographic area, and family composition. Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.

Effective July 1, 2010

• The President will have established, within the Department of Health and Human Services, a council to be known as the National Prevention, Health Promotion and Public Health Council to help begin to develop a National Prevention and Health Promotion Strategy. The Surgeon General shall serve as the Chairperson of the new Council.

Effective September 23, 2010

• Dependent children will be permitted to remain on their parents' insurance plan until their 26th birthday.
• Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.
• Insurers are prohibited from charging co-payments or deductibles for Level A or Level B preventive care and medical screenings on all new insurance plans.
• Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011. The gap will be eliminated by 2020.
• Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.
• Insurers are prohibited from dropping policyholders when they get sick.
• Insurers are required to reveal details about administrative and executive expenditures.
• Insurers are required to implement an appeals process for coverage determination and claims on all new plans.
• Indoor tanning services are subjected to a 10% service tax.
• Enhanced methods of fraud detection are implemented.
• Medicare is expanded to small, rural hospitals and facilities.
• Non-profit Blue Cross insurers are required to maintain a loss ratio (money spent on procedures over money incoming) of 85% or higher to take advantage of IRS tax benefits.
• Companies which provide early retiree benefits for individuals aged 55–64 are eligible to participate in a temporary program which reduces premium costs.
• A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.
• A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.

Effective by January 1, 2011

• Employers must disclose the value of the benefits they provided beginning in 2011 for each employee's health insurance coverage on the employees' annual Form W-2's
• Insurers will be required to spend 85% of large-group and 80% of small-group and individual plan premiums (with certain adjustments) on health care or to improve health-care quality, or return the difference to the customer as a rebate.
• The Centers for Medicare and Medicaid Services is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.

Effective by January 1, 2012

• Companies will be required to issue 1099 forms to any vendor of services or rental property to which the business has paid more than $600. Form 1099 is also sent to the IRS. Under the existing law, businesses issued the Form 1099 only to individuals who provided services or property to a business. The healthcare law included the same form be issued to corporations as well, and that the form be issued to individuals and corporations that provide property to the business. Only business related payments are reportable, personal payments not. There are a number of exceptions, for example: payments for merchandise, telephone, freight, storage, payments of rent to real estate agents are excepted. The health care bill mandate aims to collect lost revenue from companies that under-report on their tax returns. The provision is expected to raise $17 billion over 10 years. The amendments made by this section of the bill (SEC. 9006) shall apply to payments made after December 31, 2011.

Effective by January 1, 2014

• Insurers are prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.
• Insurers are prohibited from establishing annual spending caps.
• Expand Medicaid eligibility; individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.
• Two years of tax credits will be offered to qualified small businesses. In order to receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full time equivalent("FTE")employee, excluding the owner of the business, of less than $25,000 and have fewer than 11 FTEs. The subsidy is reduced by 6.7% per additional employee and 4% per additional $1,000 of average compensation. A 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.
• Impose a $2000 per employee tax penalty on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill). (In 2008, more than 95% of employers with at least 50 employees offered health insurance.)
• Set a maximum of $2000 annual deductible for a plan covering a single individual or $4000 annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
• Impose an annual penalty of $95, or up to 1% of income, whichever is greater, on individuals who do not secure insurance; this will rise to $695, or 2.5% of income, by 2016. This is an individual limit; families have a limit of $2,085. Exemptions to the fine in cases of financial hardship or religious beliefs are permitted.
• Under the CLASS Act provision, creates a new voluntary long-term care insurance program; enrollees who have paid premiums into the program and become eligible (due to disability or chronic illnesses) would receive benefits that help pay for assistance in the home or in a facility.
• Employed individuals who pay more than 9.5% of their income on health insurance premiums will be permitted to purchase insurance policies from a state-controlled health insurance option.
• Pay for new spending, in part, through spending and coverage cuts in Medicare Advantage, slowing the growth of Medicare provider payments (in part through the creation of a new Independent Payment Advisory Board), reducing Medicare and Medicaid drug reimbursement rate, cutting other Medicare and Medicaid spending.
• Revenue increases from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.
• Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.
• Establish health insurance exchanges, and subsidization of insurance premiums for individuals with income up to 400% of the poverty line, as well as single adults. Section 1401(36B) of PPACA explains that the subsidy will be provided as a advanceable, refundable tax credit and gives a formula for its calculation. Refundable tax credit is a way to provide government benefit to people even with no tax liability (example: Child Tax Credit). According to White House and Congressional Budget Office estimates, in 2016 the income-based premium caps for a "silver" healthcare plan for family of four would be the following:

Income	Premium Cap as a Share of Income	Middle of Income Range (family of 4)a	Avg Annual Enrollee Premium	Premium Subsidy (share of premium)	Avg Cost-Sharing Subsidy
100–150% of federal poverty level	2.1–4.7% of income	$30,000	$600	96%	$3,300
150–200% of federal poverty level	4.7–6.5% of income	$42,000	$2,400	83%	$1,800
200–250% of federal poverty level	6.5–8.4% of income	$54,000	$4,000	72%	0
250–300% of federal poverty level	8.4–10.2% of income	$66,000	$6,100	57%	0
300–350% of federal poverty level	10.2% of income	$78,000	$9,200	44%	0
350–400% of federal poverty level	10.2% of income	$90,100	$14,100	35%	0

a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator for specific dollar amount.

• Members of Congress and their staff will only be offered health care plans through the exchange or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).
• Earned income of individuals above $200,000 annually or couples above $250,000 annually will be subject to Medicaid Payroll withholding of 3.8%.
• Investment income of individuals above $200,000 annually or couples above $250,000 annually will be subject to Medicaid Payroll withholding of 3.8%.
• A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5 billion in annual revenue.
• Most medical devices become subject to a 2.9% excise tax collected at the time of purchase.
• Health insurance companies become subject to a new excise tax based on their market share; the rate gradually raises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3 billion in annual revenue.
• The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of earned income.

Effective by January 1, 2017

• A state may apply to the Secretary of Health & Human Services for a waiver of certain sections in the law, with respect to that state, such as the individual mandate, provided that the state develops a detailed alternative that "will provide coverage that is at least as comprehensive" and "at least as affordable" for "at least a comparable number of its residents" as the waived provisions. The decision of whether to grant this waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.

Effective by 2018

• All existing health insurance plans must cover approved preventive care and checkups without co-payment.
• A new 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill) is on the cost of coverage in excess of $27,500 (family coverage) and $10,200 (individual coverage), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.

Impact

Public policy impact

Deficit impact

See also: United States public debt

According to the CBO, the legislation will reduce the deficit by $143 billion over the first decade and by $1.2 trillion in the second decade, as compared to current legislation. The CBO has revised its estimates several times, initially projecting a savings of $132 billion, then $118 billion, and later $138 billion. The CBO estimates the cost of the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the benefits kick in. The CBO also projects revenue will exceed spending during these six years.

The CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the great degree of uncertainty involved in the data. It decided to do so in this case at the request of lawmakers. It predicted deficit reduction at about within "a broad range around one-half percent of GDP" over the 2020s while cautioning that "a wide range of changes could occur".

David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do. On the other hand, a Center on Budget and Policy Priorities analysis said that Congress has a good record of implementing Medicare savings. According to their study, Congress implemented the vast majority of the provisions enacted in the past 20 years to produce Medicare savings.

In a speech to the joint session of congress, Obama said that the law would not drive up the deficit; however, this is disputed by some.

Change in number of uninsured

According to Congressional Budget Office estimates, the number of uninsured residents will drop from current levels by 32 million people. This leaves 23 million residents who will still lack insurance in 2019 after the bill's provisions have all taken effect. Among the people in this group will be:

• Illegal immigrants, estimated at almost a third of the 23 million; they will be ineligible for insurance subsidies and Medicaid.
• Those who do not enroll in Medicaid despite being eligible.
• Those who are not otherwise covered and opt to pay the annual penalty (2.5% of income, $695 for individuals, or a maximum of $2,250 per family) instead of purchasing (presumably more expensive) insurance; this might be mostly younger and single Americans.
• Those whose insurance coverage would cost more than 8% of household income; they are exempt from paying the annual penalty.

Political impact

Public opinions and views

The Patient Protection and Affordable Care Act, and Obama's plans for health care reform in general, was often nicknamed "Obamacare". The term was usually used pejoratively, but some supporters of the act suggested after being passed that it be embraced and used positively.

A CNN poll of 1,030 adult Americans, conducted over the course of the three days preceding the health care reform bill vote in the House (March 19–21), found that 59% opposed the legislation while 39% supported it. Further breakdown of the results showed that 43% opposed the bill because it was too liberal, 13% opposed it because it was not liberal enough, and the remaining 39% supported the bill. Of the same group of respondents, 56% said the bill "gives the government too much involvement in health care," while 28% said it gives the government a "proper role" and 16% said the government's role would be "inadequate". On costs, 62% believed the bill "increases the amount of money they personally spend on health care," while 37% believed their costs would either remain the same or go down. On the fiscal impact of the bill, 70% believed it would lead to higher deficits, while 17% believed there would be no change and 12% said deficits would decrease. The margin of error was ±3 percentage points.

A USA Today/Gallup poll of 1,005 adult Americans, conducted March 22, 2010, stated that about 49% viewed the legislation as "a good thing" or otherwise reacted positively, while about 40% viewed it badly or otherwise reacted negatively. The margin of error was ±4 percentage points. Opinions were found to be starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor. A Bloomberg L.P. survey of 1,002 adult Americans, conducted March 19–22, 2010, found that about 4 in 10 supported the legislation and in comparing the findings before passing versus after passing, "no meaningful movement of opinion" occurred.

A Rasmussen Reports' survey performed before passage found only 41% of the people favored the bill and 54% opposed it. Post-passage Rasmussen polls, published March 25, stated that 55% of Americans favor repealing the bill, with a margin of error of ±3 percentage points, and that 54% of Florida voters favor the lawsuit Attorney General Bill McCollum advocates to prevent the legislation's implementation, with a margin of error of ±3 percentage points.

In March 24, CBS News released a poll finding a "small bump" in public opinion such that 42% of Americans supported the legislation compared to 46% disapproving, a change from previous support of 37% (polled just before the vote). In the newer survey, 47% approve, an increase of 6%, while 48% disapprove, a decrease of 3%. Also reported in the poll are the number of people who believe the legislation will affect them personally: 16% (down 4%) believe it will help them and 43% (up 8%) believe it will have no effect on them. Those who believed they would be negatively affected were not reported.

A post-passage Washington Post survey stated that the bill's enactment did not change public sentiment about it. A 50% majority expressed opposition and 46% expressed support. The poll had a 3% margin of error.

About trends, analyst Peter Brown of Quinnipiac has said, "The Democrats said the American people will grow to love this. We’ll find out. At this point, they’re not exactly jumping up and down."

A CNN poll on March 25-28, 2010 indicated that President Obama's approval ratings was up by five points to 51% from a week prior after passage of the health care bill. CNN reported that Obama's approval on health care policy went up to 45% from 40% from March 19-21 poll. According to Gallup poll from March 22-24 Barack Obama's job approval "stands at 51% after the passage of landmark healthcare legislation", up 5% from week before. According to CBS news polling from March 29th to April 1st reveal that 34% of respondents approve of President Obama's handling of health care and 32% approve of the health care bill signed into law. Gallup poll from April 5 shows that Obama approval on Healthcare recovers to 42% from lowest 36% before passage of the reform.

Economic opinions and analyses

The Congressional Budget Office (CBO) wrote:

The legislation would establish a mandate for most legal residents of the United States to obtain health insurance; set up insurance exchanges through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage; significantly expand eligibility for Medicaid; substantially reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law); 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.

Bloomberg wrote:

A 383-page amendment Reid offered [December 19] made some major and minor changes to the proposed legislation. Gone was a new government-run insurance program, or public option, designed to compete with private insurers. As an alternative, the U.S. Office of Personnel Management, which oversees benefits for all civilian federal workers and members of Congress, would contract with private insurers to offer multistate plans on the insurance exchange. Reid dropped plans for a tax on cosmetic surgery, dubbed the 'Bo-tax,' in favor of a 10% levy on indoor tanning salons. And he raised a Medicare payroll tax hike to 0.9%, from 0.5% earlier, on individuals earning more than $200,000 or families making more than $250,000. Reid also boosted penalties for companies that don't provide health insurance. Any company with more than 50 employees could face a penalty of $750 per worker, multiplied by the total number of full-time workers it employs, if just one obtains subsidized coverage through an exchange. That's up from a penalty of $400 in an earlier draft.

Senate Majority Leader Harry Reid said the bill would cover an additional 31 million uninsured Americans that do not have benefits, bringing full coverage to 94% of all Americans. Reid further stated that the bill will cost $848 billion over 10 years, while reducing deficits by $130 billion by adding new taxes and fees while reducing the growth of Medicare.

Surgeon Atul Gawande wrote in The New Yorker that the bill contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.

The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.

After the bill was signed, AT&T, Caterpillar, Verizon, and John Deere issued financial reports showing large current charges against earnings, up to US$1 billion in the case of AT&T, attributing the additional expenses to tax changes in the new health care law. In a letter to CEOs of the four companies, Congressmen Henry Waxman and Bart Stupak said "The new law is designed to expand coverage and bring down costs, so your assertions are a matter of concern... They also appear to conflict with independent analyses." The letters requested that the CEOs explain the charges at hearings to be held by the House Energy and Commerce Committee.

The Office of the Actuary at the Centers for Medicare and Medicaid Services released a report in April of 2010 saying that the PPACA would increase the number of Americans with health insurance coverage but would also increase projected spending by approximately 1% over 10 years. The report also cautioned that the increases could be larger, because the Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back. The report projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors. The Bill was described as "the federal government’s biggest attack on economic inequality since inequality began rising more than three decades ago".

Threats of violence

"Anger over the health-care overhaul has led to a nearly threefold increase in recent months in the number of serious threats against members of Congress," according to a federal law enforcement official interviewed by the Washington Post. "Nearly all of the recent threats appear to come from opponents of the health-care overhaul," according to Terrance W. Gainer, the current Senate Sergeant-at-Arms who previously served four years as chief of the U.S. Capitol Police.

Republican Party leaders, as well as numerous Tea Party groups, have denounced physical violence and threats as unacceptable and have urged opponents of the law to use the democratic process to change the legislation instead.

Threats caused by victim's stance on the law

The facts surrounding several of the threats indicate they were caused by the victim's position on the new law.

• Following the House vote, assassination threats against President Barack Obama were made on Twitter, and at least 10 lawmakers reported receiving threats. About ten members of Congress were assigned extra protection in the aftermath of the legislation's passage, and the threats are being investigated by the FBI.
• Windows at four Democratic offices in New York, Arizona and Kansas were shattered. A brick that was thrown through the window of a Democratic Party office in Rochester, New York, had a note attached saying "Extremism in defense of liberty is no vice", paraphrasing a quote attributed to Barry Goldwater. In Virginia, a propane line leading to a patio grill at the home of Representative Tom Perriello's brother was cut after his address was posted online allegedly by a Tea Party activist angry about the health care overhaul. According to Perriello, a threatening letter was also sent to his brother's house. Additionally, Representative Bart Stupak received death threats, and Rules Committee Chairwoman Louise Slaughter received a message saying snipers were being deployed to kill the children of those who voted for health care overhaul.
• On April 6, 2010, a Washington state man, Charles Alan Wilson, was arrested on charges that he threatened to kill U.S. Senator Patty Murray. The complaint filed by prosecutors states that several of the phone messages left by Wilson for the Senator, "expressed his strong disapproval for the health-care reform legislation, and the fact that Senator Murray voted in support of the bill".
• On April 7, 2010, a San Francisco man, Gregory Lee Giusti, was arrested on charges that he threatened U.S. House Speaker Nancy Pelosi. According to a senior law enforcement official, the threats were due to her support of health care legislation.

Threats correlated with victim's stance on the law

Some threats have been characterized as being caused by the victim's views on the law, because of the correlation of time of the threat, the victim's political party or views, or the political views or activities of the person making the threat. In these cases, there is a lack of publicly available facts showing causation.

• A Philadelphia man, Norman Leboon, was charged with threatening to kill Republican Representative Eric Cantor and his family. The two-count complaint and warrant was filed on March 29, accusing Leboon with threatening to kill Cantor and his family in a YouTube video. Politico stated that, "The arrest is the most serious in a string of threats of violence against lawmakers in wake of the divisive health care vote"; it did not list in the story specific evidence that the Cantor threat occurred due to his views on health care reform. Leboon was allegedly a donor to Obama's campaign, and the Democratic National Committee has vowed to give the money back to charity if this is concluded to be true. It also condemned threats to Cantor and his family. Prosecutors say that Laboon is not competent to stand trial because he has multiple personality disorder.
• On March 27, 2010, Tea Party movement supporters held a rally in Harry Reid's home town of Searchlight, Nevada. The rally was described as the first of a series of rallies to be held nationwide between then and income tax day, April 15, in support of conservative challengers to current members of Congress from both parties. Commentator Andrew Breitbart said that he was threatened by a group identifying themselves as Reid supporters, and that eggs were thrown at buses transporting protesters to the rally. Fox News called Breitbart's video of the encounter "inconclusive".
• Michigan Republican Party officials stated that a brick was thrown through the window of the "Fix Michigan Center" in Genoa Township during the weekend after the legislation's passage. It allegedly read "Long Live the USA" and "God Bless the USA" in black marker. There is no information that directly ties this destruction of property to health care reform or to any other specific issue.

Legal challenges

Challenges by states

Organizations and lawmakers who opposed the passage of the bill threatened to take legal action against it upon its passage. The target of the threatened lawsuits were several key provisions of the bill. Opponents claimed that fining individuals for failing to buy insurance is not within the scope of Congress's taxing powers. On March 18, before passage of the bill, the Governor of Idaho, Butch Otter, was the first state governor to put a framework together to begin a legal challenge. At least 36 other states were considering taking similar action at that time. On March 22, Attorneys General of eleven states announced their intentions to sue the federal government, citing the bill as a violation of state sovereignty and saying Congress has no authority to require individuals to purchase health insurance.

Less than an hour after the bill was signed into law on March 23, thirteen states – Florida as the lead, joined by Alabama, Colorado, Idaho, Louisiana, Michigan, Nebraska, Pennsylvania, South Carolina, South Dakota, Texas, Utah, and Washington – filed a lawsuit in U.S. District court in Pensacola challenging the bill. Twelve of the Attorneys General involved in the suit are members of the Republican Party and one, Buddy Caldwell of Louisiana, is a Democrat who was encouraged by Republican Louisiana Governor Bobby Jindal to join the suit. Subsequently, five additional states – Arizona, Indiana, Mississippi, Nevada and North Dakota – joined in Florida's suit, bringing the number of states participating to eighteen.. On April 6, Minnesota Governor Tim Pawlenty said he will sue the Federal government. State Attorney General Lori Swanson had said she did not believe a lawsuit by the state was warranted, but Pawlenty could file his own brief opposing the law in his individual capacity as governor. Pawlenty said he had not yet decided whether to join an existing suit or file separately.

In a press release, the Attorneys General indicated their primary basis for the challenge was a violation of state sovereignty. Their release stated, "The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage," and that the law puts an unfair financial burden on state governments. The lawsuit states the following legal rationale:

Regulation of non-economic activity under the Commerce Clause is possible only through the Necessary and Proper Clause. The Necessary and Proper Clause confers supplemental authority only when the means adopted to accomplish an enumerated power are 'appropriate', are 'plainly adapted to that end', and are 'consistent with the letter and spirit of the constitution.' Requiring citizen-to-citizen subsidy or redistribution is contrary to the foundational assumptions of the constitutional compact.

Virginia filed a separate suit based on a conflict between the Act and a recently enacted state law. Other states were either expected to join the multi-state lawsuit or are considering filing additional independent suits. Members of several state legislatures are attempting to counteract and prevent elements of the bill within their states. Legislators in 29 states have introduced measures to amend their constitutions to nullify portions of the health care reform law. Thirteen state statutes have been introduced to prohibit portions of the law; two states have already enacted statutory bans. Six legislatures had attempts to enact bans, but the measures were unsuccessful.

Reactions from legal experts

Justice Department spokesman Charles Miller was quoted as stating, "We are confident that this statute is constitutional and we will prevail when we defend it."

Michael C. Dorf, Professor of Law at Cornell University, wrote a lengthy analysis of present case law affecting the health care purchase mandate. He cited the 1922 Supreme Court case of Bailey v. Drexel Furniture Co. as the current precedent for invalidating Federal fines imposed via the Commerce Clause. In that case the Supreme Court ruled Congress could not impose fines through the Commerce Clause as a means to indirectly regulate activities. The case stated the Commerce Clause does not authorize Congress to "use taxation as a pretext for accomplishing a regulatory objective that it could not accomplish directly". Congress does have the power through the revenue raising clauses of the constitution to make such an imposition, but in that instance the primary purpose of the tax must be to raise revenue, "a tax that serves a revenue-raising purpose is not invalid simply because it also serves a regulatory purpose." He concluded that the revenue creation aspect trumped the questions raised by the Commerce Clause, and the ability to have the health care bill brought down by a legal case would require the court to find the fine's primary purpose is to influence behavior and effect regulations rather than provide revenue. Case law on the Commerce Clause has changed significantly since Bailey; the precedents set in United States v. Darby Lumber Co. (1941) (explicitly overturning 1918's Hammer v. Dagenhart) and 1942's Wickard v. Filburn may have an effect on the applicability of Bailey to the PPACA.

Randy Barnett, a law professor at Georgetown University, stated that a court may find some legal ground to rule portions of the bill unconstitutional.

Mark Hall, Professor of Law at Wake Forest University, specializing in health care law and policy, was quoted as saying: "Under the Due Process Clause, no Supreme Court decision since 1935 has struck down any state or federal legislation for infringing economic liberties, and any such action would be radically inconsistent with current constitutional doctrine." Regarding the attempts to override the health-care bill with state laws, Hall stated, "It doesn't make sense. The federal Constitution couldn't be any clearer that federal law is supreme," and characterized the state actions as "a kind of civil disobedience, a declaration that we're not going to follow the law of the land."

Several legal experts contacted by the Associated Press characterized the lawsuits as "futile": the lawsuits were called "pure political posturing" by constitutional law professor Robert Sedler at Wayne State University and constitutional law professor Bruce Jacob at Stetson University disparaged the lawsuit's chances and commented that the "federal government certainly can compel people to pay taxes". Constitutional law professor Jared Goldstein of Roger Williams University stated, "There was a time when these arguments would have been persuasive, and that time was 1936, when the Supreme Court declared much of the New Deal to be unconstitutional," and compared the constitutionality of the health-care bill to other social and tax legislation that was subsequently considered to be constitutional, such as Social Security or tax penalties on companies that pollute. Erwin Chemerinsky, dean and constitutional law professor of the University of California, Irvine, called the bill "clearly" constitutional, explaining that "everyone at some point is going to need health care, whether if it's for an auto accident or a communicable disease, and Congress can make sure everyone pays for the system they’re likely to benefit from."

Several lawyers and legal experts interviewed by the Los Angeles Times suggested that the precedent Gonzales v. Raich set in 2005 posed a particular hurdle for the lawsuits, because it interprets the Constitution as giving Congress "vast regulatory authority over interstate commerce" and is a precedent set by several members of the existing Supreme Court (including conservative Justices Scalia and Kennedy). However, constitutional law professor Adam Winkler of UCLA noted that the current Supreme Court "has already shown itself to be willing to break from long-standing precedent in major cases" and "precedent rarely dictates how the court will rule" on "hot-button, partisan issues", although Winkler also disparaged the argument that Congress could not penalize people for failure to purchase health insurance.

Challenges by private organizations

Liberty University and the Thomas More Law Center each filed suit raising freedom-of-religion (i.e. 1st Amendment) challenges, namely (a) that the bill violates their right to practice their religious beliefs, which oppose nationalized health insurance and its provisions for abortion; and (b) that it unconstitutionally recognizes certain religious groups (such as the Amish and Old Order Mennonites), but not others, as eligible for exemption.

See also

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• Comparison of Canadian and American health care systems
• Universal health care

External links

• HealthCare.gov - Information including FAQ on health care changes
• Full Video of bill signing ceremony (from C-SPAN)

Copies of the proposed bill hosted online or readily downloadable

• Plain Text or PDF formats of H.R. 3590, as engrossed or passed by the Senate and printed via FDsys. Dec. 24
• The Patient Protection and Affordable Care Act, full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov)
• Summary of H.R. 3590 (March 23, 2010) via THOMAS.
• Entry for H.R. 3590 at GovTrack
• The law as published by the U.S. Government Printing Office

Latest Congressional Budget Office scoring (all previous scoring for now superseded Senate bills no longer applies)

• Patient Protection and Affordable Care Act, Incorporation of the Manager's Amendment, SA 3276 − December 19, 2009
  • Correction Regarding the Manager's Amendment to the Patient Protection and Affordable Care Act − December 20, 2009
• Base Analysis – H.R. 3590, Patient Protection and Affordable Care Act, − November 18, 2009.
  ↑ (The Additional and/or Related CBO reporting that follows can be accessed from the above link)
  • Budgetary Treatment of Proposals to Regulate Medical Loss Ratios − Dec. 13
  • Additional Information about Employment-Based Coverage − Dec. 7
  • Estimated Average Premiums Under Current Law − Dec. 5
  • An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act − Nov. 30
  • Additional Information on CLASS Program Proposals − Nov. 25
  • Estimated Effects on the Status of the Hospital Insurance Trust Fund − Nov. 21
  • Estimated Effects on Medicare Advantage Enrollment and Benefits Not Covered by Medicare − Nov. 21
  • Estimated Distribution of Individual Mandate Penalties − Nov. 20
  • Analysis of Subsidies and Payments at Different Income Levels − Nov. 20

Centers for Medicare and Medicaid Services 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

Centers for Medicare and Medicaid Services 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

Additional commercially hosted information complimenting H.R. 3590

• Comparison of House and Senate bills. "Key Differences in the Health Care Plans". The New York Times. November 19, 2009. Retrieved May 21, 2010.
• Chris L. Peterson, A Comparative Analysis of Private Health Insurance Provisions of H.R. 3962 and S.Amdt. 2786 to H.R. 3590, Congressional Research Service, R40981, December 16, 2009
• Kaiser Family Foundation: Health Reform Subsidy Calculator -- Premium Assistance for Coverage in Exchanges/Gateways