Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare or the Affordable Care Act, is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

PPACA is aimed at increasing the rate of health insurance coverage for Americans and reducing the overall costs of health care. It provides a number of mechanisms—including mandates, subsidies, and tax credits—to employers and individuals in order to increase the coverage rate. Additional reforms aim to improve healthcare outcomes and streamline the delivery of health care. PPACA requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or sex. The Congressional Budget Office projected that PPACA will lower both future deficits and Medicare spending.

On June 28, 2012, the United States Supreme Court upheld the constitutionality of most of PPACA in the case National Federation of Independent Business v. Sebelius.

Provisions


PPACA includes numerous provisions to take effect over several years beginning in 2010. There is a grandfather clause on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies.
 * Guaranteed issue will require policies to be issued regardless of any medical condition, and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most pre-existing conditions (excluding tobacco use).
 * A shared responsibility requirement, commonly called an individual mandate, requires that all individuals not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs, secure an approved private-insurance policy or pay a penalty, unless the applicable individual is a member of a recognized religious sect exempted by the Internal Revenue Service, or waived in cases of financial hardship.
 * Health insurance exchanges will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).
 * Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies on a sliding scale if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income).
 * The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of the poverty level, effectively 138%, and simplifies the CHIP enrollment process. In National Federation of Independent Business v. Sebelius, the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this may create a coverage gap in those states.
 * Minimum standards for health insurance policies are to be established and annual and lifetime coverage caps will be banned.
 * Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.
 * Very small businesses will be able to get subsidies if they purchase insurance through an exchange.
 * Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package" for Level A or Level B preventive care.
 * Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payment." A single payment is paid to a hospital and a physician group, for example, for a defined episode of care (such as a hip replacement), rather than individual payments to individual service-providers.

Funding
PPACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened Medicare tax on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% excise tax on "Cadillac" insurance policies. The income levels are not adjusted for inflation, leaving the possibility of increased taxes on incomes over 250,000 inflation-adjusted dollars after more than two decades without indexing through. There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal sales tax on indoor tanning services. Offsets are from intended cost savings such as changes in the Medicare Advantage program relative to traditional Medicare.

Summary of tax increases: (ten-year projection) Summary of spending offsets: (ten year projection)
 * Increase Medicare tax rate by .9% and impose added tax of 3.8% on unearned income for high-income taxpayers: $210.2 billion
 * Charge an annual fee on health insurance providers: $60 billion
 * Impose a 40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family: $32 billion
 * Impose an annual fee on manufacturers and importers of branded drugs: $27 billion
 * Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20 billion
 * Raise the 7.5% Adjusted Gross Income floor on medical expenses deduction to 10%: $15.2 billion
 * Limit annual contributions to flexible spending arrangements in cafeteria plans to $2,500: $13 billion
 * All other revenue sources: $14.9 billion
 * Reduce funding for Medicare Advantage policies: $132 billion
 * Reduce Medicare home health care payments: $40 billion
 * Reduce certain Medicare hospital payments: $22 billion

Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17 billion, but the provision was repealed.

Provisions by effective date
PPACA is divided into ten titles and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020. Below are some of the key provisions of PPACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.

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 (paid by drug manufacturers to the states) 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.
 * A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research. This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input. The bill forbids the Institute to develop or employ "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's National Institute for Health and Clinical Excellence.
 * 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.
 * 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. But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.
 * States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.

Effective June 21, 2010

 * Adults with existing conditions became 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. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.

Effective July 1, 2010

 * The President established, within the Department of Health and Human Services (HHS), 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.
 * A 10% sales tax on indoor tanning took effect.

Effective September 23, 2010

 * Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.
 * Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday, and regulations implemented under PPACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.
 * Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.
 * All new insurance plans must cover preventive care and medical screenings rated Level A or B by the U.S. Preventive Services Task Force. Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.
 * 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.
 * Enhanced methods of fraud detection are implemented.
 * Medicare is expanded to small, rural hospitals and facilities.
 * Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses.
 * 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.
 * All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.

Effective January 1, 2011

 * Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.
 * 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.
 * Flexible spending accounts, Health reimbursement accounts and health savings accounts cannot be used to pay for over-the-counter drugs, purchased without a prescription, except insulin.

Effective September 1, 2011

 * All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.

Effective January 1, 2012

 * Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's. This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010. Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.


 * New tax reporting changes were to come in effect. Lawmakers originally felt these changes would help prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses. Before PPACA businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600. Under the repealed law, reporting of payments to corporations would also be required.  Originally it was expected to raise $17 billion over 10 years. The amendments made by Section 9006 of PPACA were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.

Effective August 1, 2012

 * All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services – including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing. This is also known as the contraceptive mandate.

Effective October 1, 2012

 * The Centers for Medicare & Medicaid Services (CMS) will begin the Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (§412.150 through §412.154). Starting in October, an estimated total of 2,217 hospitals across the nation will be penalized; however, only 307 of these hospitals will receive this year's maximum penalty, i.e., 1 percent off their base Medicare reimbursements. The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. Together, these 2,217 hospitals will forfeit more than $280 million in Medicare funds over the next year, i.e., until October 2013, as Medicare and Medicaid begin a wide-ranging push to start paying health care providers based on the quality of care they provide. The $280 million in penalties comprises about 0.3 percent of the total amount hospitals are paid by Medicare.

Effective January 1, 2013

 * Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately. In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)


 * Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.


 * Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.) This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in veterinary medicine.

Effective by August 1, 2013

 * Religious organizations that were given an extra year to implement the contraceptive mandate are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.

Effective by January 1, 2014



 * Insurers are prohibited from discriminating against or charging higher rates for any individuals based on gender or pre-existing medical conditions.
 * Insurers are prohibited from establishing annual spending caps.
 * Individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of income over the filing minimum, whichever is greater; this will rise to a minimum of $695 ($2,085 for families), or 2.5% of income over the filing minimum, by 2016. Exemptions to the mandatory coverage provision and penalty are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income.
 * In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children. As written, PPACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled, in National Federation of Independent Business v. Sebelius, that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. As of February 26, 2013, ten states -- Idaho, South Dakota, Maine, Texas, Oklahoma, Alabama, Mississippi, Louisiana, Georgia, and South Carolina—had announced that they would decline to participate in the Medicaid expansion, and four more -- Wyoming, Nebraska, Iowa, and Virginia—were leaning towards declining.
 * Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.
 * Impose a $2,000 per employee 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). Full-time is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.
 * For employer sponsored plans, set a maximum of $2,000 annual deductible for a plan covering a single individual or $4,000 annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
 * The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped. The CLASS Act was repealed January 1, 2013.


 * 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.
 * Establish health insurance exchanges, and subsidization of insurance premiums for individuals in households with income up to 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. Section 1401(36B) of PPACA explains that the subsidy will be provided as an 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: Earned Income Credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for family of four would be the following:
 * The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.
 * 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).
 * 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.
 * Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises 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 adjusted gross income (AGI).
 * Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.

Effective by October 1, 2014

 * Federal payments to so-called 'disproportionate share hospitals', which treat large numbers of indigent patients, are to be reduced and subsequently allowed to rise based on the percentage of the population that is uninsured in each state.

Effective by January 1, 2015

 * CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.

Effective by October 1, 2015

 * States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.

Effective by January 1, 2016

 * States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.
 * The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.

Effective by January 1, 2017

 * A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period. A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage. The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan. In order to qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions. A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later. In April 2011 Vermont announced its intention to pursue a waiver in order to implement the single-payer system enacted in May 2011.    In September 2011 Montana announced it would also be seeking a waiver to set up its own single payer healthcare system.
 * States may allow large employers and multi-employer health plans to purchase coverage in the Exchange.
 * Two federally regulated 'multi-state plan' (MSP) insurers, with one being non-profit and the other being forbidden from providing coverage for abortion services, will be available to all states. They will have to oblige by the same federal regulations as required by individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016 with full national coverage in 2017.

Effective by January 1, 2018

 * All existing health insurance plans must cover approved preventive care and checkups without co-payment.
 * A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill) is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), 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.

Effective by January 1, 2019

 * Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old

Effective by January 1, 2020

 * The Medicare Part D coverage gap (a.k.a., "donut hole") will be completely phased out and hence closed.

Background
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 be 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. In July 2009, a series of bills were approved by committees within the House of Representatives. On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members met for a series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators Max Baucus (D-Montana), Chuck Grassley (R-Iowa), Kent Conrad (D-North Dakota), Olympia Snowe (R-Maine), Jeff Bingaman (D-New Mexico), and Mike Enzi (R-Wyoming), met for more than 60 hours, and the principles that they discussed became the foundation of the Senate's health care reform bill. The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site or at the Committee's own web site.

The reform negotiations attracted a great deal of attention from lobbyists, including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1996. The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.

During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the 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.

To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline 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 reform proposals that ultimately became the Senate bill, the Patient Protection and Affordable Care Act, bore similarities to prior healthcare reform proposals introduced by Republicans. The bill's drafters had deliberately drawn on bipartisan ideas to increase the chances of getting the necessary votes for passage. In particular, the idea of an individual mandate coupled with subsidies for private insurance, as an alternative to public insurance, was considered a way to get Universal Health Insurance that could win the support of the Senate. Many healthcare policy experts have pointed out that the "individual mandate" requirement to buy health insurance was contained in many previous Republican/conservative proposals for healthcare legislation, going back as far as 1989. Among these past proposals: In 1993 Senator John Chafee introduced the Health Equity and Access Reform Today Act which contained a "Universal Coverage" requirement with a penalty for non-compliance. Advocates for the 1993 bill which contained the "individual mandate" included prominent Republicans who today oppose the mandate, namely Orrin Hatch (R-UT), Charles Grassley (R-IA), Robert Bennett (R-UT), and Christopher Bond (R-MO). In 1994 Senator Don Nickles introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision. However, Nickles removed the mandate from the act shortly after introduction, stating that they had decided "that government should not compel people to buy health insurance."

Experts have also pointed out that the healthcare legislation that emerged from Congress in 2009 and 2010 is patterned, largely, after former Republican Governor of Massachusetts Mitt Romney's state healthcare plan which also contains the individual mandate. In addition to having received bipartisan support in Massachusetts, the PPACA drafters believed they could win support by showing areas of success of the Massachusetts reform and building on it's ideas to achieve a national system. The same adviser, Jonathan Gruber, who had worked on reform in Massachusetts, consulted the drafters of the PPACA.

There were many threats made against members of Congress and many were assigned extra protection.

Senate
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 would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees.

With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary in order to get passage in the Senate. Initially, at the start of the 111th Congress, Democrats had only 58 votes (the Senate seat in Minnesota that would be won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican). To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try and bring aboard several Republican Senators (particular attention was given to Bob Bennett, Chuck Grassley, Mike Enzi, and Olympia Snowe). Negotiations continued even after July 7 - when Al Franken was sworn into the Senate and by which time Senator Arlen Specter had switched parties - because of disagreements over the bill's substance (which was still being drafted in Committee), and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy (a staunch and long-time advocate for Health Care Reform) succumbed to his terminal brain cancer, depriving Democrats of a crucial 60th vote. Attention was drawn to Senator Snowe as the potential replacement because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly warned that this did not mean she would support the final bill.

When Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24, regaining Democrat's 60th vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut Senator Joe Lieberman (an independent who caucused with Democrats) and Nebraska Senator Ben Nelson. Senator Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was removed. With every other Democrat now in favour and every other Republican now overtly opposed, The White House and Reid moved on to addressing Senator Nelson's concerns; they had by this point concluded that "it was a waste of time dealing with [Snowe]" because, after her vote for the draft bill in the Finance Committee, Senator Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform. (Snowe choose to retire at the end of her term citing partisanship and polarization).

After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges" (requiring consumers to pay for the procedure out-of-pocket, if the state decided it); and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska. The latter half of the compromise was derisively referred to as the "Cornhusker Kickback" (and was later repealed by the subsequent reconciliation amendment bill).

On December 23, the Senate voted 60–39 to end debate on the bill (a cloture vote to end the filibuster by opponents). The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two Independents voting for, and all Republicans voting against except one Republican senator (Jim Bunning, R-Ky.) not voting. The bill was endorsed by the AMA and AARP.

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace Senator Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even famously signing autographs as "Scott 41."

House
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. White House Chief of Staff Rahm Emanuel argued the Democrats should scale-back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care". Obama remained insistent on 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 to reassure nervous Democrats after Scott Brown's win. On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills. He also held a meeting, on February 25, 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.

With Democrats having lost a filibuster-proof majority in the Senate, but having already passed the Senate bill with 60 votes on December 23; 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 pass the Senate's bill (The Patient Protection and Affordable Care Act) instead. Various health policy experts encouraged the House to pass the Senate version of the bill. However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a (House-Senate) Conference before passing a final bill. With that option off the table (as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster); the House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill (ultimately the Health Care and Education Reconciliation Act), which could be passed via the reconciliation process. Unlike the regular order, reconciliation is not subject to a filibuster (which requires 60 votes to break), but the process is limited to budget changes, which is why it was never able to be used to pass a comprehensive reform bill (with its inherently non-budgetary regulations as in the PPACA) in the first place. Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."

The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, 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. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as they were obviously outside the scope of the process with its budgetary limits. Instead, 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 original bill (the PPACA) into law on March 23, 2010. The amendment bill (the Health Care and Education Reconciliation Act) was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.

Change in number of uninsured
CBO originally estimated the legislation will reduce the number of uninsured residents by 32 million, leaving 23 million uninsured residents in 2019 after the bill's provisions have all taken effect. A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the successful legal challenge to PPACA's expansion of Medicaid.

Among the people in this uninsured group will be:
 * Illegal immigrants, estimated to be around eight million – they will be ineligible for insurance subsidies and Medicaid;  they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA).
 * Citizens not enrolled in Medicaid despite being eligible.
 * Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.
 * Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.
 * Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.

Early experience under PPACA was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time. On September 13, 2011, the Census Bureau released a report showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%. A later report from the Government Accountability Office in 2012 found that of the 4 million small businesses that were offered the tax credit only 170,300 businesses claimed it. Due to the effect of the U.S. Supreme court ruling, states can opt-in or out of the expansion of Medicaid. Arkansas, California, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont, and Washington are implementing the expansion; Florida, Louisiana, Mississippi, Georgia, South Carolina, and Texas are not.

Also, in part due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26; in September 2010 some insurance companies announced that in response to the law, they would end the issuance of new child-only policies. Kentucky Insurance Commissioner Sharon Clark said the decision by insurers to stop offering such policies was a violation of state law and ordered insurers to offer an open enrollment period in January 2011 for Kentuckians under 19. An August 2011 Congressional report found that passage of the health care law prompted health insurance carriers to stop selling new child-only health plans in many states. Of the 50 states, 17 reported that there were currently no carriers selling child only health plans to new enrollees. Thirty-nine states indicated at least one insurance carrier exited the child-only market following enactment of the health care laws.

Effects on insurance premiums
For the effect on health insurance premiums, the CBO referred to its November 2009 analysis and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.

The Associated Press reported that, as a result of PPACA's provisions concerning the Medicare Part D coverage gap (between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription drug program), individuals falling in this "donut hole" would save about 40 percent. Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies. The change benefited more than two million people, most of them in the middle class.

The non-partisan Congressional Budget Office estimates that "about 4 million" (3.9 million or 1.2% of the population) will pay the penalty in 2016. In September 2012, the CBO estimated that nearly six million will pay a $1,200 penalty in 2016. Also, nearly 80 percent of those who will face the penalty would be making up to or less than five times the federal poverty level. This would work out to $55,850 or less for an individual and $115,250 or less for a family of four.

In January 2013, the Internal Revenue Service ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the worker’s household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. The New York Times said this could leave millions of Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies to buy coverage elsewhere.

Coverage for contraceptives
The PPACA includes a contraceptive coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations made under PPACA rely on the recommendations of the Institute of Medicine, which concluded that access to contraception is medically necessary "to ensure women's health and well-being."

The initial regulations proved controversial among Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds. To accommodate those concerns whilst still guaranteeing access to contraception, the regulations were adjusted to "allow religious organizations to opt out of the requirement to include birth control coverage in their employee insurance plans. In those instances, the insurers themselves will offer contraception coverage to enrollees directly, at no additional cost."

CBO deficit reduction estimates
The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021. CBO estimated in March 2011 that for the 2012–2021 period, the law would result in net receipts of $813 billion, offset by $604 billion in outlays, resulting in a $210 billion reduction in the deficit.

In 2012, the CBO updated its cost estimates for a portion of the bill, but did not update its estimate of the net deficit impact of the whole bill (which was still estimated to reduce budget deficits overall). The ACA's provisions related to insurance coverage were projected earlier in 2012 to have a net cost of $1,252 billion over the 2012–2022 period; that amount represented a gross cost to the federal government of $1,762 billion, offset in part by $510 billion in receipts and other budgetary effects (primarily revenues from penalties and other sources). The addition of 2022 to the projection period had the effect of increasing the costs of the coverage provisions of the ACA relative to those projected in March 2011 for the 2012-2021 period because that change added a year in which the expansion of eligibility for Medicaid and the subsidies for health insurance purchased through the exchanges would have been in effect. This estimate was made prior to the Supreme Court's ruling regarding the expansion of Medicaid program to the individual states however. CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of $1,168 billion over the 2012–2022 period—compared with $1,252 billion projected in March 2012 for that 11-year period—for a net reduction of $84 billion. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)

As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143 billion over the first decade, but half of that was due to expected premiums for the C.L.A.S.S. Act, which has since been abandoned. Although 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, and estimated a second decade deficit reduction of $1.2 trillion. CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".

CBO also initially stated that the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs;" A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019;    however, the "doc fix" remains a separate piece of legislation. Subject to the same exclusion, the CBO initially estimated the federal government's share of the cost during the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the spending kicks in; with revenue exceeding spending during these six years.

Opinions on CBO projections
There was mixed opinion about the CBO estimates.

Uwe Reinhardt, a health economist at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003."

Douglas Holtz-Eakin, CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.

The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (a noted health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation; "innovations in the delivery of medical care, like greater use of electronic medical records and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another – and that meant there wasn't much hard data to prove the savings would materialize."

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. The Center on Budget and Policy Priorities objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings.

Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700 billion in its first 10 years.

Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false and that repeal of the legislation would increase the deficit by $230 billion over the same period, pointing to the CBO's 2011 analysis of the impact of repeal.

Effect on health care cost trends
In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:
 * Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."

Jonathan Gruber, an influential consultant who helped develop both the Affordable Care Act and the Massachusetts Health Care reform that preceded it, acknowledges that the Affordable Care Act is not guaranteed to significantly 'bend the curve' of rising health care costs:
 * "The real question is how far the ACA will go in slowing cost growth. Here, there is great uncertainty—mostly because there is such uncertainty in general about how to control cost growth in health care. There is no shortage of good ideas for ways of doing so... There is, however, a shortage of evidence regarding which approaches will actually work—and therefore no consensus on which path is best to follow. In the face of such uncertainty, the ACA pursued the path of considering a range of different approaches to controlling health care costs... Whether these policies by themselves can fully solve the long run health care cost problem in the United States is doubtful. They may, however, provide a first step towards controlling costs—and understanding what does and does not work to do so more broadly."

The law created the Center for Medicare and Medicaid Innovation and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run. Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.

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.

Expenditure estimates
In 2012, the Congressional Budget Office (CBO) projected PPACA will require more than $1.7 trillion in gross federal spending over the period 2012–2022, some of which will be offset by penalties and tax increases related to coverage, resulting in net spending of more than $1.2 trillion for the insurance portion of the bill. However, this is only a partial accounting for the impact of the bill, excluding some offsetting expense reductions and revenue increases that result in a net deficit reduction.

According to the Centers for Medicare and Medicaid Services, by 2019 PPACA will increase expenditures on Medicaid and individual subsidies by $165 billion annually while reducing Medicare expenditures by $125 billion annually. The United States Department of Health and Human Services reported that the bill would increase "total national health expenditures" by more than $200 billion from 2010 to 2019. 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: They projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors. The Medicare Actuary report still concluded that "Additional Federal revenues would further offset the coverage costs; however, the Office of the Actuary does not have the expertise necessary to estimate all such impacts. The Congressional Budget Office and the Joint Committee on Taxation have estimated an overall reduction in the Federal Budget deficit through 2019 under the PPACA."

Public opinion
Polls indicate support of health care reform in general, but became more negative in regards to specific plans during the legislative debate over 2009 and 2010, and the Act that was ultimately signed in 2010 remains controversial with opinions falling along party lines. Polling averages show a plurality with negative opinions of the law, with those in favor trailing by single digits. USA Today found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.

Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. Democrats favor the law, while most Republicans and Independents did not. For example, a Reuters-Ipsos poll during June 2012 indicated the following:
 * 56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall.
 * 82% favored banning insurance companies from denying coverage to people with pre-existing conditions.
 * 61% favored allowing children to stay on their parents' insurance until age 26.
 * 72% supported requiring companies with more than 50 employees to provide insurance for their employees.
 * 61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.
 * Other polls showed additional provisions receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.
 * Other specific ideas that were not enacted but which showed majority support included purchasing drugs from Canada, limiting malpractice awards, and reducing the age to qualify for Medicare,.

Pollsters probed the reasons for opposition. In a CNN poll, 62% of respondents said they thought the PPACA would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they thought they and their families would be better off with the legislation. In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen wrote, "81% of voters say it's likely the plan will end up costing more than projected [and 59%] say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care. For these voters, the notion that you need to spend an additional trillion dollars doesn't make sense." However, a June 2012 Reuters-Ipsos poll indicated that part of the opposition to the law was because some Americans did not believe the reform went far enough and wanted more done, not less. Among those opposed to the bill, 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among (the relative much smaller group of) Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.

Following the Supreme Court decision upholding the Act, a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."

Term "Obamacare"
The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. However by mid-2012 it was the common term used by both sides. Use of the term in a positive sense was suggested by Democratic politicians such as John Conyers (D-MI). President Obama said subsequently, "I have no problem with people saying Obama cares. I do care." Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased Google advertisements, triggered by the term, to direct people to the official HHS site. In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post Twitter messages that begin, "I like #Obamacare because...". According to an analysis by the Sunlight Foundation, the term "Obamacare" has been used nearly 3,000 times in Congressional speeches since its debut as a phrase on Capitol Hill in July 2009.

According to The New York Times, the term was first put in print in March 2007, when health care lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s", Schulte Scott wrote. The expression Obamacare first was used in early 2007 generally by writers describing the candidate’s proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at The Atlantic magazine. The word was first uttered in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said: "In my state, I worked on health care for some time. We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over health care'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."

Working hours for part-time employees
In 2013, the State of Virginia limited all part-time employees, from janitors to adjunct professors, to working no more than 29 hours per week so that they would not qualify for mandatory health insurance coverage under the law. Florida’s Palm Beach State College, Pennsylvania’s Community College of Allegheny County, Ohio’s Youngstown State University, and New Jersey’s Kean University have instituted similar rules, as have restaurants such as Applebee's, Olive Garden, Denny's, Red Lobster, Papa John's Pizza, and some Wendy's and Taco Bell franchises.

Legal challenges
Opponents of the Patient Protection and Affordable Care Act have turned to the federal courts to challenge the constitutionality of the legislation. The Supreme Court upheld the individual mandate (5-4) on the basis that it is a tax rather than protection under the Commerce Clause, but determined that States could not be forced to participate in the expansion of Medicaid. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.

111th Congress
Reps. Steve King of Iowa and Michele Bachmann of Minnesota, both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. Jim DeMint in the Senate. None of the three bills were considered by either body.

112th Congress
In 2011, the Republican-controlled House of Representatives voted 245–189 to approve a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2), which, if enacted, would repeal the Patient Protection and Affordable Care Act and the health care-related text of the Health Care and Education Reconciliation Act of 2010. All Republicans and 3 Democrats voted for repeal. In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down. Before votes in both houses of the Congress took place, President Obama stated that he would veto the bill should it pass both chambers. Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program. The Republicans voted down this measure.

On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader Eric Cantor stated that the House would again vote to repeal the law in July when Congress returns from recess. On July 11, 2012, the House of Representatives voted to repeal the law with 5 Democrats and all 239 Republicans voting in favor of the repeal. This was the 31st effort by the House of Representatives to repeal the bill in the 112th Congress. With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, Republicans conceded that repeal almost certainly will not occur.

Job consequences of repeal
One argument put forth in favor of repeal was that, as stated by a spokesman for House Majority Leader Eric Cantor, "This is a job-killing law, period." The House Republican leadership justified its use of the term "job killing" by contending that PPACA would lead to a loss of 650,000 jobs, and attributing that figure to a report by the Congressional Budget Office. However, FactCheck noted the 650,000 figure was not included in the CBO report that was referred to, and said that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect [on employment] 'will probably be small.'" PolitiFact also rated the Republican statement as False.

Jonathan Cohn, citing the projections of the CBO, summarized that the primary employment effect of the PPACA is to alleviate job-lock: "people who are only working because they desperately need employer-sponsored health insurance will no longer do so." He concluded that "reform’s only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire" once they have health insurance outside of their jobs.

Effect of repeal proposals on federal budget projections
The non-partisan Congressional Budget Office (CBO) estimated that repealing the entire PPACA (including both its taxing and spending provisions) would increase the net 2011–2021 federal deficit by $210 billion. Republican politicians disagreed, arguing that estimate was based on unrealistic assumptions; House Speaker John Boehner said, "I don't think anyone in this town believes that repealing Obamacare is going to increase the deficit." In May 2011, CBO analyzed proposals to prevent the use of appropriated funds to implement the legislation, and wrote that "a temporary prohibition, extending through the remainder of fiscal year 2011, would reduce the budget deficit by about $1.4 billion in 2011 but would increase deficits by almost $6 billion over the 2011–2021 period... CBO cannot determine whether changes in spending under a permanent prohibition would produce net costs or net savings relative to its baseline projection, which assumes full implementation."

Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R. 6079) on July 11, 2012 and taking into account the Supreme Court's ruling concerning the expansion of Medicaid by the States, that, on balance, the direct spending and revenue effects of enacting the Repeal of Obamacare Act legislation would cause a net increase in federal budget deficits of $109 billion over the 2013–2022 period. Specifically, CBO estimates that H.R. 6079 would reduce direct spending by $890 billion and reduce revenues by $1 trillion between 2013 and 2022, thus adding $109 billion to federal budget deficits over that period.

Temporary waivers
Interim regulations have been put in place for a specific type of employer-funded insurance, the so-called "mini-med" or limited-benefit plans, which are low-cost to employers who buy them for their employees, but cap coverage at a very low level. Such plans are sometimes offered to low-paid and part-time workers, for example in fast food restaurants or purchased direct from an insurer. Most company-provided health insurance policies starting on or after September 23, 2010 and before September 23, 2011 may not set an annual coverage cap lower than $750,000, a lower limit that is raised in stages until 2014, by which time no insurance caps are allowed at all. By 2014, no health insurance, whether sold in the individual or group market, will be allowed to place an annual cap on coverage. The waivers have been put in place to encourage employers and insurers offering mini-med plans not to withdraw medical coverage before the full regulations come into force (by which time small employers and individuals will be able to buy non-capped coverage through the exchanges) and are granted only if the employer can show that complying with the limit would mean a significant decrease in employees' benefits coverage or a significant increase in employees' premiums.

Among those receiving waivers were employers, large insurers, such as Aetna and Cigna, and union plans covering about one million employees. McDonald's, one of the employers that received a waiver, has 30,000 hourly employees whose plans have annual caps of $10,000. The waivers are issued for one year and can be reapplied for. Referring to the adjustments as "a balancing act", Nancy-Ann DeParle, director of the Office of Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014." On January 26, 2011, HHS said it had to date granted a total of 733 waivers for 2011, covering 2.1 million people, or about 1% of the privately insured population. In June 2011, the Obama Administration announced that all applications for new waivers and renewals of existing ones have to be filed by September 22 of that year, and no new waivers would be approved after this date.