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Implementation history of the Affordable Care Act

The Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) or nicknamed Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.[1][2][3][4] Once the law was signed, provisions began taking effect, in a process that continued for years. Some provisions never took effect, while others were deferred for various periods.[citation needed]

Existing individual health plans edit

Plans purchased after the date of enactment, March 23, 2010, or old plans that changed in specified ways would eventually have to be replaced by ACA-compliant plans.[citation needed]

At various times during and after the ACA debate, Obama stated that "if you like your health care plan, you'll be able to keep your health care plan".[5][6] However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,[7] and several million more risked seeing their current plans cancelled.[8][9][10]

Obama's previous unambiguous assurance that consumers' could keep their own plans became a focal point for critics, who challenged his truthfulness.[11][12] On November 7, 2013, President Obama stated: "I am sorry that [people losing their plans] are finding themselves in this situation based on assurances they got from me."[13] Various bills were introduced in Congress to allow people to keep their plans.[14]

In late 2013, the Obama Administration announced a transitional relief program that would let states and carriers allow non-compliant individual and small group policies to renew at the end of 2013. In March 2014, HHS allowed renewals as late as October 1, 2016. In February 2016, these plans were allowed to renew up until October 1, 2017, but with a termination date no later than December 31, 2017.[citation needed]

2010 edit

In June small business tax credits took effect. For certain small businesses, the credits reached up to 35% of premiums. At the same time, uninsured people with pre-existing conditions could access the federal high-risk pool. Also, participating employment-based plans could obtain reimbursement for a portion of the cost of providing health insurance to early retirees.[15]

In July the Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those that had been denied coverage by private insurance companies because of a pre-existing condition. Despite estimates of up to 700,000 enrollees, at a cost of approximately $13,000/enrollee, only 56,257 enrolled at a $28,994 cost per enrollee.[15]

2011 edit

As of September 23, 2010, pre-existing conditions could no longer be denied coverage for children's policies. HHS interpreted this rule as a mandate for "guaranteed issue", requiring insurers to issue policies to such children.[citation needed] By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement.[16]

The average beneficiary in the prior coverage gap would have spent $1,504 in 2011 on prescriptions. Such recipients saved an average $603. The 50 percent discount on brand name drugs provided $581 and the increased Medicare share of generic drug costs provided the balance. Beneficiaries numbered 2 million[17]

2012 edit

In National Federation of Independent Business v. Sebelius decided on June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional when the associated penalties were construed as a tax. The decision allowed states to opt out of the Medicaid expansion. Several did so,[18] although some later accepted the expansion.[19][20]

2013 edit

In January 2013, the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold. This was estimated to leave 2–4 million Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies.[21][22]

A June 2013, study found that the MLR provision had saved individual insurance consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%.[23] The bulk of the savings were in reduced premiums, but some came from MLR rebates.

On July 2, 2013, the Obama Administration announced that it would delay the implementation of the employer mandate until 2015.[24][25][26]

The Community Living Assistance Services and Supports Act (or CLASS Act) was enacted as Title VIII of the ACA. It would have created a voluntary and public long-term care insurance option for employees.[27][28] In October 2011 the administration announced it was unworkable and would be dropped.[29] The CLASS Act was repealed January 1, 2013.[30]

The launch for both the state and federal exchanges was troubled due to management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered endless problems.[31] Operations stabilized in 2014, although not all planned features were complete.[32][33]

CMS reported in 2013 that, while costs per capita continued to rise, the rate of increase in annual healthcare costs had fallen since 2002. Per capita cost increases averaged 5.4% annually between 2000 and 2013. Costs relative to GDP, which had been rising, had stagnated since 2009.[34] Several studies attempted to explain the reductions. Reasons included:

  • Higher unemployment due to the 2008–2010 recession, which limited the ability of consumers to purchase healthcare;
  • Out-of-pocket costs rose, reducing demand for healthcare services.[35] The proportion of workers with employer-sponsored health insurance requiring a deductible climbed to about three-quarters in 2012 from about half in 2006.[36]
  • ACA changes[36] that aim to shift the healthcare system from paying-for-quantity to paying-for-quality. Some changes occurred due to healthcare providers acting in anticipation of future implementation of reforms.[37][38]

2014 edit

On July 30, 2014, the Government Accountability Office released a non-partisan study that concluded that the administration did not provide "effective planning or oversight practices" in developing the ACA website.[39]

In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.[40] In Wheaton College vs Burwell the Court issued an injunction allowing the evangelical college and other religiously affiliated nonprofit groups to completely ignore the contraceptive mandate.[41]

A study found that average premiums for the second-cheapest ( silver) plan were 10–21% less than average individual market premiums in 2013, while covering many more conditions. Credit for the reduced premiums was attributed to increased competition stimulated by the larger market, greater authority to review premium increases, the MLR and risk corridors.[citation needed]

Many of the initial plans featured narrow networks of doctors and hospitals.[42][failed verification]

A 2016 analysis found that health care spending by the middle class was 8.9% of household spending in 2014.[43]

2015 edit

By the beginning of the year, 11.7 million had signed up (ex-Medicaid).[44] On December 31, 2015, about 8.8 million consumers had stayed in the program. Some 84 percent, or about 7.4 million, were subsidized.[45]

Bronze plans were the second most popular in 2015, making up 22% of marketplace plan selections. Silver plans were the most popular, accounting for 67% of marketplace selections. Gold plans were 7%. Platinum plans accounted for 3%. On average across the four metal tiers, premiums were up 20% for HMOs and 18% for EPOs. Premiums for POS plans were up 15% from 2015 to 2016, while PPO premiums were up just 8%.[citation needed]

A 2015 study found 14% of privately insured consumers received a medical bill in the past two years from an out-of-network provider in the context of an overall in-network treatment event. Such out-of-network care is not subject to the lower negotiated rates of in-network care, increasing out-of-pocket costs. Another 2015 study found that the average out-of-network charges for the majority of 97 medical procedures examined "were 300% or higher compared to the corresponding Medicare fees" for those services.[citation needed]

Some 47% of the 2015 ACA plans sold on the Healthcare.gov exchange lacked standard out-of-network coverage. Enrollees in such plans typically received no coverage for out-of-network costs (except for emergencies or with prior authorization). A 2016 study on Healthcare.gov health plans found a 24 percent increase in the percentage of ACA plans that lacked standard out-of-network coverage.[citation needed]

The December spending bill delayed the onset of the "Cadillac tax" on expensive insurance plans by two years, until 2020.[46]

The average price of non-generic drugs rose 16.2% in 2015 and 98.2% since 2011.[43]

2016 edit

As of March 2016 11.1 million people had purchased exchange plans, while an estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults.[citation needed] 11.1 million were still covered, a decline of nearly 13 percent.[47] 6.1 million uninsured 19- to 25-year-olds gained coverage.[48]

Employers edit

A survey of New York businesses found an increase of 8.5 percent in health care costs, less than the prior year's survey had expected. A 10 percent increase was expected for 2017. Factors included increased premiums, higher drug costs, ACA and aging workers. Some firms lowered costs by increasing cost-sharing (for higher employee contributions, deductibles and co-payments). 60% planned to further increase cost-sharing. Coverage and benefits were not expected to change. Approximately one fifth said ACA had pushed them to reduce their workforce. A larger number said they were raising prices.[49]

Insurers edit

The five major national insurers expected to lose money on ACA policies in 2016.[50] UnitedHealth withdrew from the Georgia and Arkansas exchanges for 2017, citing heavy losses.[51] Humana exited other markets, leaving it operating in 156 counties in 11 states for 2017.[52] 225 counties across the country had access to only a single ACA insurer. A study released in May estimated that 664 counties would have one insurer in 2017.[53][failed verification]

Aetna cancelled planned expansion of its offerings and following an expected $300 million loss in 2016 and then withdrew from 11 of its 15 states.[54] In August 2016 Anthem said that its offerings were losing money, but also that it would expand its participation if a pending merger with Cigna was approved.[55] Aetna and Humana's exit for 2017 left 8 rural Arizona counties with only Blue Cross/Blue Shield.[56]

Blue Cross/Blue Shield Minnesota announced that it would exit individual and family markets in Minnesota in 2017, due to financial losses of $500 million over three years.[57]

Another analysis found that 17 percent of eligibles may have a single insurer option in 2017. North Carolina, Oklahoma, Alaska, Alabama, South Carolina and Wyoming were expected to have a single insurer,[58] while only 2 percent of 2016 eligibles had only one choice.[59]

Aetna, Humana, UnitedHealth Group also exited various individual markets. Many local Blue Cross plans sharply narrowed their networks. In 2016 two thirds of individual plans were narrow-network HMO plans.[42]

One of the causes of insurer losses is the lower income, older and sicker enrollee population. One 2016 analysis reported that while 81% of the population with incomes from 100 to 150% of the federal poverty level signed up, only 45% of those from 150 to 200% did so. The percentage continued to decline as income rose: 2% of those above 400% enrolled.[60]

Costs edit

The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance, based on income levels. Higher income consumers receive lower subsidies. While pre-subsidy prices rose considerably from 2016 to 2017, so did the subsidies, to reduce the after-subsidy cost to the consumer. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas.[61] However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reported that for the second-lowest cost "Silver plan" (a plan often selected and used as the benchmark for determining financial assistance), a 40-year-old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the subsidy/tax credit, despite large increases in the pre-subsidy price. This was consistent nationally. In other words, the subsidies increased along with the pre-subsidy price, fully offsetting the price increases.[62]

Cooperatives edit

The number of ACA nonprofit insurance cooperatives for 2017 fell from 23 originally to 7 for 2017. The remaining 7 posted annual losses in 2015. A General Accountability Report found that co-ops’ 2015 premiums were generally below average. At the end of 2014, money co-ops and other ACA insurers had counted on risk corridor payments that didn't materialize. Maryland's Evergreen Health claims that ACA's risk-adjustment system does not adequately measure risk.[citation needed]

Medicaid edit

Newly elected Louisiana Governor John Bel Edwards issued an executive order to accept the expansion, becoming the 32nd state to do so. The program was expected to enroll an additional 300,000 Louisianans.[63]

2017 edit

 
Tax Cuts and Jobs Act - Number of additional persons uninsured.[64]

More than 9.2 million people signed up for care on the national exchange (healthcare.gov) for 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump, who pulled advertising encouraging people to sign up for coverage, issued an executive order that attempts to eliminate the mandate, and has created significant uncertainty about the future of the ACA. Enrollments had been running ahead of 2016 prior to President Obama leaving office, with 9.8 million expected to sign-up, so President Trump's actions potentially cost about 600,000 national enrollments (i.e., 9.8 million expected − 9.2 million actual = 0.6 million impact).[65] Of the 9.2 million, 3.0 million were new customers and 6.2 million were returning. The 9.2 million excludes the 11 states that run their own exchanges, which have signed up around 3 million additional people.[65] These figures also exclude the additional coverage due to the Medicaid expansion, which covers another approximately 10 million persons, as described in the impact section above.

In February, Humana announced that it would withdraw from the individual insurance market in 2018, citing "further signs of an unbalanced risk pool."[66] That month the IRS announced that it would not require that tax returns indicate that a person has health insurance, reducing the effectiveness of the individual mandate, in response to an executive order from President Donald Trump.[67]

Aetna CEO Mark Bertolini stated that ACA was in a "death spiral" of escalating premiums and shrinking, skewed enrollment.[68] However, a U.S. judge found that the Aetna CEO misrepresented why his company was leaving the exchanges; an important part of the reason was the Justice Department's opposition to the intended merger between Aetna and Humana. Aetna announced that it would exit the exchange market in all remaining states.[69] It stated that its losses had grown from $100M in 2014 to $450M in 2016.[70] Wellmark withdrew from Iowa in April.[71] As of May, no insurer had indicated its intention to offer ACA insurance in Nebraska.[69] Also in May Blue Cross and Blue Shield of Kansas City announced it would withdraw from Missouri and Kansas's individual markets in 2018, potentially leaving nearly 19,000 residents in Western Missouri without a coverage option.[72] Anthem announced plans to withdraw from Ohio[73] and later Wisconsin[74] and Indiana,[75] describing the market as "volatile" and referring to the difficulty in pricing its plans "due to the shrinking individual market as well as continual changes in federal operations, rules and guidance."[73]

The CBO reported in March 2017 that the healthcare exchanges were expected to be stable; i.e., they were not in a "death spiral."[76] In June, Centene announced that it intended to initiate coverage in Nevada, Kansas and Missouri and expand coverage in Ohio and Florida.[77]

Molina Healthcare, a major Medicaid provider, said that it was considering exiting some markets in 2018, citing "too many unknowns with the marketplace program." Molina lost $110 million in 2016 due to having to contribute $325 million more than expected to the ACA "risk transfer" fund that compensated insurers with unprofitable risk pools. These pools were established to help prevent insurers from artificially selecting lower-risk pools.[78]

In May the United States House of Representatives voted to repeal the ACA using the American Health Care Act of 2017.[79][80]

On December 20, 2017, the individual mandate was repealed starting in 2019 via the Tax Cuts and Jobs Act of 2017.[81] The CBO estimated that the repeal would cause 13 million people to lose their health insurance by 2027.[82]

2019 edit

By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicare or via an alternative program.[83]

Murray—Alexander Individual Market Stabilization Bill edit

Senator Lamar Alexander and Senator Patty Murray reached a compromise to amend the Affordable Care Act to fund cost cost-sharing reductions.[84] President Trump had stopped paying the cost sharing subsidies and the Congressional Budget Office estimated his action would cost $200 billion, cause insurance sold on the exchange to cost 20% more and cause one million people to lose insurance.[85] The proposed legislation will also provide more flexibility for state waivers, allow a new "Copper Plan" or catastrophic coverage for all, allow interstate insurance compacts, and redirect consumer fees to states for outreach.

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External links edit

PPACA text edit

  • Codification in U.S. Code is generally at 42 U.S.C. 18001 et sqq. To read it, start at GPO FDsys by selecting, in the Year menu, the most recent year that lists Title 42. In Title 42, seek section 18001 and subsequent sections.
  • Public Law 111–148 after consolidating the amendments made by PPACA Title X and by HCERA.
  • Full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov)
  • Public Law 111–148 U.S. Government Printing Office

implementation, history, affordable, care, patient, protection, affordable, care, often, shortened, affordable, care, nicknamed, obamacare, united, states, federal, statute, enacted, 111th, united, states, congress, signed, into, president, barack, obama, marc. The Patient Protection and Affordable Care Act often shortened to the Affordable Care Act ACA or nicknamed Obamacare is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23 2010 Together with the Health Care and Education Reconciliation Act of 2010 amendment it represents the U S healthcare system s most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965 1 2 3 4 Once the law was signed provisions began taking effect in a process that continued for years Some provisions never took effect while others were deferred for various periods citation needed Contents 1 Existing individual health plans 2 2010 3 2011 4 2012 5 2013 6 2014 7 2015 8 2016 8 1 Employers 8 2 Insurers 8 3 Costs 8 4 Cooperatives 8 5 Medicaid 9 2017 10 2019 11 Murray Alexander Individual Market Stabilization Bill 12 References 13 External links 13 1 PPACA textExisting individual health plans editPlans purchased after the date of enactment March 23 2010 or old plans that changed in specified ways would eventually have to be replaced by ACA compliant plans citation needed At various times during and after the ACA debate Obama stated that if you like your health care plan you ll be able to keep your health care plan 5 6 However in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated 7 and several million more risked seeing their current plans cancelled 8 9 10 Obama s previous unambiguous assurance that consumers could keep their own plans became a focal point for critics who challenged his truthfulness 11 12 On November 7 2013 President Obama stated I am sorry that people losing their plans are finding themselves in this situation based on assurances they got from me 13 Various bills were introduced in Congress to allow people to keep their plans 14 In late 2013 the Obama Administration announced a transitional relief program that would let states and carriers allow non compliant individual and small group policies to renew at the end of 2013 In March 2014 HHS allowed renewals as late as October 1 2016 In February 2016 these plans were allowed to renew up until October 1 2017 but with a termination date no later than December 31 2017 citation needed 2010 editIn June small business tax credits took effect For certain small businesses the credits reached up to 35 of premiums At the same time uninsured people with pre existing conditions could access the federal high risk pool Also participating employment based plans could obtain reimbursement for a portion of the cost of providing health insurance to early retirees 15 In July the Pre Existing Condition Insurance Plan PCIP took effect to offer insurance to those that had been denied coverage by private insurance companies because of a pre existing condition Despite estimates of up to 700 000 enrollees at a cost of approximately 13 000 enrollee only 56 257 enrolled at a 28 994 cost per enrollee 15 2011 editAs of September 23 2010 pre existing conditions could no longer be denied coverage for children s policies HHS interpreted this rule as a mandate for guaranteed issue requiring insurers to issue policies to such children citation needed By 2011 insurers had stopped marketing child only policies in 17 states as they sought to escape this requirement 16 The average beneficiary in the prior coverage gap would have spent 1 504 in 2011 on prescriptions Such recipients saved an average 603 The 50 percent discount on brand name drugs provided 581 and the increased Medicare share of generic drug costs provided the balance Beneficiaries numbered 2 million 17 2012 editIn National Federation of Independent Business v Sebelius decided on June 28 2012 the Supreme Court ruled that the individual mandate was constitutional when the associated penalties were construed as a tax The decision allowed states to opt out of the Medicaid expansion Several did so 18 although some later accepted the expansion 19 20 2013 editIn January 2013 the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9 5 of income Family plans would not be considered even if the cost was above the 9 5 income threshold This was estimated to leave 2 4 million Americans unable to afford family coverage under their employers plans and ineligible for subsidies 21 22 A June 2013 study found that the MLR provision had saved individual insurance consumers 1 2 billion in 2011 and 2 1 billion in 2012 reducing their 2012 costs by 7 5 23 The bulk of the savings were in reduced premiums but some came from MLR rebates On July 2 2013 the Obama Administration announced that it would delay the implementation of the employer mandate until 2015 24 25 26 The Community Living Assistance Services and Supports Act or CLASS Act was enacted as Title VIII of the ACA It would have created a voluntary and public long term care insurance option for employees 27 28 In October 2011 the administration announced it was unworkable and would be dropped 29 The CLASS Act was repealed January 1 2013 30 The launch for both the state and federal exchanges was troubled due to management and technical failings HealthCare gov the website that offers insurance through the exchanges operated by the federal government crashed on opening and suffered endless problems 31 Operations stabilized in 2014 although not all planned features were complete 32 33 CMS reported in 2013 that while costs per capita continued to rise the rate of increase in annual healthcare costs had fallen since 2002 Per capita cost increases averaged 5 4 annually between 2000 and 2013 Costs relative to GDP which had been rising had stagnated since 2009 34 Several studies attempted to explain the reductions Reasons included Higher unemployment due to the 2008 2010 recession which limited the ability of consumers to purchase healthcare Out of pocket costs rose reducing demand for healthcare services 35 The proportion of workers with employer sponsored health insurance requiring a deductible climbed to about three quarters in 2012 from about half in 2006 36 ACA changes 36 that aim to shift the healthcare system from paying for quantity to paying for quality Some changes occurred due to healthcare providers acting in anticipation of future implementation of reforms 37 38 2014 editOn July 30 2014 the Government Accountability Office released a non partisan study that concluded that the administration did not provide effective planning or oversight practices in developing the ACA website 39 In Burwell v Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule 40 In Wheaton College vs Burwell the Court issued an injunction allowing the evangelical college and other religiously affiliated nonprofit groups to completely ignore the contraceptive mandate 41 A study found that average premiums for the second cheapest silver plan were 10 21 less than average individual market premiums in 2013 while covering many more conditions Credit for the reduced premiums was attributed to increased competition stimulated by the larger market greater authority to review premium increases the MLR and risk corridors citation needed Many of the initial plans featured narrow networks of doctors and hospitals 42 failed verification A 2016 analysis found that health care spending by the middle class was 8 9 of household spending in 2014 43 2015 editBy the beginning of the year 11 7 million had signed up ex Medicaid 44 On December 31 2015 about 8 8 million consumers had stayed in the program Some 84 percent or about 7 4 million were subsidized 45 Bronze plans were the second most popular in 2015 making up 22 of marketplace plan selections Silver plans were the most popular accounting for 67 of marketplace selections Gold plans were 7 Platinum plans accounted for 3 On average across the four metal tiers premiums were up 20 for HMOs and 18 for EPOs Premiums for POS plans were up 15 from 2015 to 2016 while PPO premiums were up just 8 citation needed A 2015 study found 14 of privately insured consumers received a medical bill in the past two years from an out of network provider in the context of an overall in network treatment event Such out of network care is not subject to the lower negotiated rates of in network care increasing out of pocket costs Another 2015 study found that the average out of network charges for the majority of 97 medical procedures examined were 300 or higher compared to the corresponding Medicare fees for those services citation needed Some 47 of the 2015 ACA plans sold on the Healthcare gov exchange lacked standard out of network coverage Enrollees in such plans typically received no coverage for out of network costs except for emergencies or with prior authorization A 2016 study on Healthcare gov health plans found a 24 percent increase in the percentage of ACA plans that lacked standard out of network coverage citation needed The December spending bill delayed the onset of the Cadillac tax on expensive insurance plans by two years until 2020 46 The average price of non generic drugs rose 16 2 in 2015 and 98 2 since 2011 43 2016 editAs of March 2016 11 1 million people had purchased exchange plans while an estimated 9 million to 10 million people had gained Medicaid coverage mostly low income adults citation needed 11 1 million were still covered a decline of nearly 13 percent 47 6 1 million uninsured 19 to 25 year olds gained coverage 48 Employers edit A survey of New York businesses found an increase of 8 5 percent in health care costs less than the prior year s survey had expected A 10 percent increase was expected for 2017 Factors included increased premiums higher drug costs ACA and aging workers Some firms lowered costs by increasing cost sharing for higher employee contributions deductibles and co payments 60 planned to further increase cost sharing Coverage and benefits were not expected to change Approximately one fifth said ACA had pushed them to reduce their workforce A larger number said they were raising prices 49 Insurers edit The five major national insurers expected to lose money on ACA policies in 2016 50 UnitedHealth withdrew from the Georgia and Arkansas exchanges for 2017 citing heavy losses 51 Humana exited other markets leaving it operating in 156 counties in 11 states for 2017 52 225 counties across the country had access to only a single ACA insurer A study released in May estimated that 664 counties would have one insurer in 2017 53 failed verification Aetna cancelled planned expansion of its offerings and following an expected 300 million loss in 2016 and then withdrew from 11 of its 15 states 54 In August 2016 Anthem said that its offerings were losing money but also that it would expand its participation if a pending merger with Cigna was approved 55 Aetna and Humana s exit for 2017 left 8 rural Arizona counties with only Blue Cross Blue Shield 56 Blue Cross Blue Shield Minnesota announced that it would exit individual and family markets in Minnesota in 2017 due to financial losses of 500 million over three years 57 Another analysis found that 17 percent of eligibles may have a single insurer option in 2017 North Carolina Oklahoma Alaska Alabama South Carolina and Wyoming were expected to have a single insurer 58 while only 2 percent of 2016 eligibles had only one choice 59 Aetna Humana UnitedHealth Group also exited various individual markets Many local Blue Cross plans sharply narrowed their networks In 2016 two thirds of individual plans were narrow network HMO plans 42 One of the causes of insurer losses is the lower income older and sicker enrollee population One 2016 analysis reported that while 81 of the population with incomes from 100 to 150 of the federal poverty level signed up only 45 of those from 150 to 200 did so The percentage continued to decline as income rose 2 of those above 400 enrolled 60 Costs edit The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance based on income levels Higher income consumers receive lower subsidies While pre subsidy prices rose considerably from 2016 to 2017 so did the subsidies to reduce the after subsidy cost to the consumer For example a study published in 2016 found that the average requested 2017 premium increase among 40 year old non smokers was about 9 percent according to an analysis of 17 cities although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas 61 However some or all of these costs are offset by subsidies paid as tax credits For example the Kaiser Foundation reported that for the second lowest cost Silver plan a plan often selected and used as the benchmark for determining financial assistance a 40 year old non smoker making 30 000 per year would pay effectively the same amount in 2017 as they did in 2016 about 208 month after the subsidy tax credit despite large increases in the pre subsidy price This was consistent nationally In other words the subsidies increased along with the pre subsidy price fully offsetting the price increases 62 Cooperatives edit The number of ACA nonprofit insurance cooperatives for 2017 fell from 23 originally to 7 for 2017 The remaining 7 posted annual losses in 2015 A General Accountability Report found that co ops 2015 premiums were generally below average At the end of 2014 money co ops and other ACA insurers had counted on risk corridor payments that didn t materialize Maryland s Evergreen Health claims that ACA s risk adjustment system does not adequately measure risk citation needed Medicaid edit Newly elected Louisiana Governor John Bel Edwards issued an executive order to accept the expansion becoming the 32nd state to do so The program was expected to enroll an additional 300 000 Louisianans 63 2017 edit nbsp Tax Cuts and Jobs Act Number of additional persons uninsured 64 More than 9 2 million people signed up for care on the national exchange healthcare gov for 2017 down some 400 000 from 2016 This decline was due primarily to the election of President Trump who pulled advertising encouraging people to sign up for coverage issued an executive order that attempts to eliminate the mandate and has created significant uncertainty about the future of the ACA Enrollments had been running ahead of 2016 prior to President Obama leaving office with 9 8 million expected to sign up so President Trump s actions potentially cost about 600 000 national enrollments i e 9 8 million expected 9 2 million actual 0 6 million impact 65 Of the 9 2 million 3 0 million were new customers and 6 2 million were returning The 9 2 million excludes the 11 states that run their own exchanges which have signed up around 3 million additional people 65 These figures also exclude the additional coverage due to the Medicaid expansion which covers another approximately 10 million persons as described in the impact section above In February Humana announced that it would withdraw from the individual insurance market in 2018 citing further signs of an unbalanced risk pool 66 That month the IRS announced that it would not require that tax returns indicate that a person has health insurance reducing the effectiveness of the individual mandate in response to an executive order from President Donald Trump 67 Aetna CEO Mark Bertolini stated that ACA was in a death spiral of escalating premiums and shrinking skewed enrollment 68 However a U S judge found that the Aetna CEO misrepresented why his company was leaving the exchanges an important part of the reason was the Justice Department s opposition to the intended merger between Aetna and Humana Aetna announced that it would exit the exchange market in all remaining states 69 It stated that its losses had grown from 100M in 2014 to 450M in 2016 70 Wellmark withdrew from Iowa in April 71 As of May no insurer had indicated its intention to offer ACA insurance in Nebraska 69 Also in May Blue Cross and Blue Shield of Kansas City announced it would withdraw from Missouri and Kansas s individual markets in 2018 potentially leaving nearly 19 000 residents in Western Missouri without a coverage option 72 Anthem announced plans to withdraw from Ohio 73 and later Wisconsin 74 and Indiana 75 describing the market as volatile and referring to the difficulty in pricing its plans due to the shrinking individual market as well as continual changes in federal operations rules and guidance 73 The CBO reported in March 2017 that the healthcare exchanges were expected to be stable i e they were not in a death spiral 76 In June Centene announced that it intended to initiate coverage in Nevada Kansas and Missouri and expand coverage in Ohio and Florida 77 Molina Healthcare a major Medicaid provider said that it was considering exiting some markets in 2018 citing too many unknowns with the marketplace program Molina lost 110 million in 2016 due to having to contribute 325 million more than expected to the ACA risk transfer fund that compensated insurers with unprofitable risk pools These pools were established to help prevent insurers from artificially selecting lower risk pools 78 In May the United States House of Representatives voted to repeal the ACA using the American Health Care Act of 2017 79 80 On December 20 2017 the individual mandate was repealed starting in 2019 via the Tax Cuts and Jobs Act of 2017 81 The CBO estimated that the repeal would cause 13 million people to lose their health insurance by 2027 82 2019 editBy 2019 35 states and the District of Columbia had either expanded coverage via traditional Medicare or via an alternative program 83 Murray Alexander Individual Market Stabilization Bill editMain article Murray Alexander Individual Market Stabilization Bill Senator Lamar Alexander and Senator Patty Murray reached a compromise to amend the Affordable Care Act to fund cost cost sharing reductions 84 President Trump had stopped paying the cost sharing subsidies and the Congressional Budget Office estimated his action would cost 200 billion cause insurance sold on the exchange to cost 20 more and cause one million people to lose insurance 85 The proposed legislation will also provide more flexibility for state waivers allow a new Copper Plan or catastrophic coverage for all allow interstate insurance compacts and redirect consumer fees to states for outreach References edit Oberlander Jonathan June 1 2010 Long Time Coming Why Health Reform Finally Passed Health Affairs 29 6 1112 1116 doi 10 1377 hlthaff 2010 0447 ISSN 0278 2715 PMID 20530339 Blumenthal David Abrams Melinda Nuzum Rachel 18 June 2015 The Affordable Care Act at 5 Years New England Journal of Medicine 372 25 2451 2458 doi 10 1056 NEJMhpr1503614 ISSN 0028 4793 PMID 25946142 S2CID 28486139 Cohen Alan B Colby David C Wailoo Keith A Zelizer Julian E 1 June 2015 Medicare and Medicaid at 50 America s Entitlement Programs in the Age of Affordable Care Oxford University Press ISBN 9780190231569 Vicini James Stempel Jonathan Biskupic Joan 28 June 2017 Top court upholds healthcare law in Obama triumph Reuters A Town Hall and a Health Care Model in Green Bay whitehouse gov 11 June 2009 Retrieved November 9 2013 via National Archives Jacobson Louis Barack Obama says that what he d said was you could keep your plan if it hasn t changed since the law passed PolitiFact Retrieved November 9 2013 After the big Obamacare apology where things stand CNN November 8 2013 Retrieved November 9 2013 Obama apologizes for insurance cancellations due to Obamacare CNN 7 November 2013 Retrieved July 29 2014 Obama blames bad apple insurers for canceled coverage Reuters com October 30 2013 Sealover Ed November 8 2013 Health insurers say they re canceling plans because of federal law Denver Business Journal Retrieved November 9 2013 Weigel David November 8 2013 The White House s Website Still Says If You Like Your Plan You Can Keep It Slate Retrieved November 9 2013 Obamacare The debacle The Economist November 2 2013 Retrieved November 8 2013 Obama apologizes to Americans who lost health plans Fox News November 8 2013 Retrieved November 9 2013 Schoof Renee November 8 2013 Congress weighing laws to let people keep health insurance McClatchyDC Retrieved November 14 2013 a b History of the Affordable Care Act ACA October 22 2014 Enzi Michael B August 2 2011 Health Care Reforrm Law s Impact on Child Only Health Insurance Policies PDF United States Senate Retrieved August 10 2016 RICARDO ALONSO ZALDIVAR Report Medicare s drug coverage gap shrinks Associated Press Retrieved August 7 2016 Liptak Adam September 30 2012 Supreme Court justices face important rulings in upcoming term September The New York Times Archived from the original on November 14 2012 Retrieved September 30 2012 Status of State Action on the Medicaid Expansion Decision Kaiser Family Foundation Retrieved August 12 2016 Walton Alice G How To Explain The Obamacare Ruling To A Five Year Old Forbes Retrieved 5 May 2017 A Cruel Blow to American Families The New York Times February 2 2013 Cohn Jonathan February 5 2013 Not So Universal Health Care The New Republic Cox Cynthia Claxton Gary Levitt Larry June 6 2013 Beyond Rebates How Much Are Consumers Saving from the ACA s Medical Loss Ratio Provision Kaiser Family Foundation Retrieved June 9 2013 Cohn Jonathan July 2 2013 Some Bad News About Obamacare That Isn t Bogus The New Republic Mazur Mark Continuing to Implement the ACA in a Careful Thoughtful Manner United States Department of the Treasury Retrieved July 16 2013 Madara Matthew R February 11 2014 ACA Employer Shared Responsibility Delay Included in Final Regs Tax Notes Today 2014 TNT 28 1 Span Paula March 29 2010 Options Expand for Affordable Long Term Care The New York Times Retrieved March 29 2010 Carney Timothy February 28 2011 So yeah the health care bill was really an awful piece of legislation that sent the revolving door spinning faster permanent dead link Washington Examiner Obama drops long term health care program CNN com CNN October 17 2011 Watchdogs CLASS still dead LifeHealthPro January 2 2013 Archived from the original on August 12 2015 Retrieved April 6 2018 Kennedy Kelly December 1 2013 White House claims success on HealthCare gov repairs USA Today Retrieved December 1 2013 Cohen Tom October 23 2013 Rough Obamacare rollout 4 reasons why CNN Retrieved November 5 2013 Holland Steve Rampton Roberta November 6 2013 Senate Democrats frustrated with botched rollout of Obamacare The Christian Science Monitor Reuters Retrieved November 19 2013 Statistics Trends and Reports Centers for Medicare and Medicaid Services Retrieved September 23 2013 Cohn Jonathan April 12 2011 More Skin in the Game for Seniors The New Republic a b Lowrey Annie May 7 2013 Slowdown in Rise of Healthcare Costs May Persist The New York Times Retrieved June 10 2013 Chait Jonathan May 29 2013 Yuval Levin Dissembles Madly New York Chait Jonathan May 10 2013 The Facts Are In and Paul Ryan Is Wrong New York Alonso Zaldivar Ricardo July 31 2014 Probe exposes flaws behind HealthCare gov rollout AP News Retrieved July 31 2014 Burwell v Hobby Lobby 573 U S United States Supreme Court 2014 Adler Jonathan A July 3 2014 Supreme Court grants Wheaton College an injunction against contraception mandate accommodation The New York Times Retrieved 9 July 2014 a b Sanger Katz Margot August 19 2016 Think Your Obamacare Plan Will Be Like Employer Coverage Think Again The New York Times ISSN 0362 4331 Retrieved August 26 2016 a b Sussman Anna Louie August 26 2016 Burden of Health Care Costs Moves to the Middle Class Wall Street Journal ISSN 0099 9660 Retrieved August 31 2016 Tracer Zachary 2 June 2015 Obamacare Sign Ups Decline to 10 2 Million as Some Don t Pay Bloomberg com Retrieved August 21 2016 December 31 2015 Effectuated Enrollment Snapshot cms gov March 11 2016 COOK NANCY December 16 2015 How the White House lost on the Cadillac Tax Politico Retrieved August 21 2016 About 1 6M drop outs from ObamaCare coverage this year Fox News Associated Press June 30 2016 Retrieved August 21 2016 ASPA Assistant Secretary for Public Affairs March 3 2016 20 million people have gained health insurance coverage because of the Affordable Care Act new estimates show HHS gov Retrieved August 22 2016 Supplemental Survey Report Empire State Manufacturing Survey Business Leaders Survey Firms Assess Effects of Affordable Care Act PDF Federal Reserve Bank of New York August 2016 Mathews Anna Wilde August 16 2016 Aetna to Drop Some Affordable Care Act Markets Wall Street Journal ISSN 0099 9660 Retrieved August 16 2016 Nussbaum Alex March 4 2015 Health Insurance Exchanges Bloomberg View Retrieved August 12 2016 Humana pulling out of many Obamacare markets Politico Retrieved August 15 2016 Following Some Withdrawals More Counties Could Have One ACA Marketplace Insurer in 2017 16 May 2016 Retrieved August 19 2016 Chakraborty Barnini August 10 2016 ObamaCare problems deepen as insurers scramble to stem losses Fox News Fox News Retrieved August 15 2016 Tracer Zachary 2 August 2016 Aetna s Obamacare Reversal Is Latest Blow to U S Health Law Bloomberg com Retrieved August 12 2016 Alltucker Ken Obamacare insurers dwindle as Humana UnitedHealthcare exit Arizona The Arizona Republic Retrieved August 12 2016 Zdechlik Mark 24 June 2016 Minnesota s Largest Health Insurer Will Drop Individual Plans NPR Retrieved August 26 2016 Goldstein Amy October 14 2016 In North Carolina ACA insurer defections leave little choice for many consumers Washington Post Retrieved October 16 2016 Abelson Reed Sanger katz Margot August 19 2016 Obamacare Options In Many Parts of Country Only One Insurer Will Remain The New York Times ISSN 0362 4331 Retrieved August 21 2016 Ip Greg August 17 2016 The Unstable Economics in Obama s Health Law Wall Street Journal ISSN 0099 9660 Retrieved August 23 2016 Mali Meghashyam August 11 2016 Next president faces possible ObamaCare meltdown Retrieved August 15 2016 2017 Premium Changes and Insurer Participation in the Affordable Care Act s Health Insurance Marketplaces Kaiser Family Foundation November 2016 Retrieved November 23 2016 Louisiana to Expand Medicaid Outlook for the States in 2016 Families USA Retrieved August 22 2016 NYT Steven Rattner 2017 The Year in Charts December 29 2017 a b Affordable Care Act signups dip amid uncertainty and Trump attacks NYT February 3 2017 Coombs Bertha 2017 02 14 Humana to quit Obamacare exchanges in 2018 providing fuel for Trump s repeal efforts CNBC Retrieved 2017 02 15 Morton Victor February 14 2017 IRS weakens enforcement of Obamacare individual mandate Report The Washington Times Retrieved 2017 02 16 Aetna CEO Obamacare markets are in a death spiral POLITICO Retrieved 2017 02 16 a b Aetna exiting all ACA insurance marketplaces in 2018 Washington Post Retrieved 2017 05 11 Coombs Dan Mangan Bertha May 3 2017 Aetna will exit Obamacare markets in Virginia in 2018 citing expected losses on individual plans this year CNBC a href Template Cite web html title Template Cite web cite web a CS1 maint multiple names authors list link Obamacare just suffered 2 big blows from insurance companies as repeal looms Business Insider Retrieved 2017 05 09 Luhby Tami 2017 05 24 Nearly 19 000 in Missouri could be stranded after insurer pulls out of Obamacare CNNMoney Retrieved 2017 06 07 a b Mathews Anna Wilde June 6 2017 Anthem s Exit From Ohio Exchange Ups Ante for GOP Health Overhaul The Wall Street Journal Arp Jessica 2017 06 21 Anthem to withdraw from Wisconsin health insurance marketplace Channel3000 com Retrieved 2017 06 22 Groppe Maureen June 21 2017 Two of four insurers will no longer sell Obamacare plans in Indiana Indianapolis Star Retrieved 2017 06 22 American Healthcare Act Cost Estimate PDF Congressional Budget Office March 13 2017 Sanger katz Margot Abelson Reed 2017 06 13 Trump Says Market Is Failing but One Insurer Bets Big on Obamacare The New York Times ISSN 0362 4331 Retrieved 2017 06 25 Tracer Zachary 2017 02 15 One Insurer Says Obamacare in Death Spiral Another May Quit Bloomberg com Retrieved 2017 02 17 House Passes Bill to Repeal Obamacare Live Updates WSJ Retrieved 5 May 2017 Epstein Reid J 5 May 2017 Analyst Sees Danger for House Republicans After Health Bill Vote WSJ Retrieved 5 May 2017 Hatch Orrin December 20 2017 Sen Orrin Hatch Repealing the individual mandate tax is the beginning of the end of the ObamaCare era Fox News Retrieved December 21 2017 O Brien Elizabeth December 2 2017 The Senate s Tax Bill Eliminates the Individual Mandate for Health Insurance Here s What You Need to Know Money Archived from the original on April 29 2022 Where the states stand on Medicaid expansion Advisory com February 6 2019 Thomas Kaplan Robert Pear 17 October 2017 2 Senators Strike Deal on Health Subsidies That Trump Cut Off The New York Times CBO says Trump s Obamacare sabotage would cost 194 billion drive up premiums 20 Vox Retrieved 2017 10 17 External links editImplementation history of the Affordable Care Act at Wikipedia s sister projects nbsp Media from Commons nbsp News from Wikinews nbsp Texts from Wikisource PPACA text edit Codification in U S Code is generally at 42 U S C 18001 et sqq To read it start at GPO FDsys by selecting in the Year menu the most recent year that lists Title 42 In Title 42 seek section 18001 and subsequent sections Public Law 111 148 after consolidating the amendments made by PPACA Title X and by HCERA Full text summary background provisions and more via Democratic Policy Committee Senate gov Public Law 111 148 U S Government Printing Office Retrieved from https en wikipedia org w index php title Implementation history of the Affordable Care Act amp oldid 1181773347, wikipedia, wiki, book, books, library,

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