Affordable Care Act: Difference between revisions

[[File:View From the Speaker's Office Tonight (4452690853).jpg|thumb|right|[[Jim Clyburn]] and Nancy Pelosi celebrate after the House passes the amended bill on March 21.]]

{{Further|Commission on Key National Indicators}}

===Other insurance provisions===

Consumer Operated and Oriented Plans (CO-OP), member-governed non-profit insurers, could start providing health care coverage, based on a 5-year federal loan.<ref>{{Cite web |url=https://www.cms.gov/CCIIO/Programs-and-Initiatives/Insurance-Programs/Consumer-Operated-and-Oriented-Plan-Program.html |title=Consumer Operated and Oriented Plan Program |first1=Centers for |last1=Medicare |first2=Medicaid Services 7500 Security Boulevard |last2=Baltimore |first3=Md21244 |last3=Usa |date=May 8, 2013 |website=www.cms.gov |access-date=July 24, 2019 |archive-date=October 24, 2019 |archive-url=https://web.archive.org/web/20191024010226/https://www.cms.gov/CCIIO/Programs-and-Initiatives/Insurance-Programs/Consumer-Operated-and-Oriented-Plan-Program.html |url-status=live }}</ref> As of 2017, only four of the original 23 co-ops were still in operation.<ref>{{Cite web | last =  Small |  first = Leslie  |archive-url = https://web.archive.org/web/20170818133103/https://www.fiercehealthcare.com/payer/one-just-four-co-ops-left-montana-insurer-returns-from-hiatus-high-hopes |  archive-date = August 18, 2017 |url=https://www.fiercehealthcare.com/payer/one-just-four-co-ops-left-montana-insurer-returns-from-hiatus-high-hopes |title=Montana CO-OP, 1 of just 4 left, returns from hiatus with high hopes| publisher = Questex |location = Newton MA |website=FierceHealthcare |date=August 14, 2017 |access-date=December 1, 2019}}</ref>

[[File:U.S. Senator John Chafee.jpg|thumb|John Chafee]]

[[File:P112912PS-0444 - President Barack Obama and Mitt Romney in the Oval Office - crop.jpg|thumb|Mitt Romney's [[Massachusetts]] went from 90% of its residents insured to 98%, the highest rate in the nation.<ref>{{cite news | first1 =  Drew  | last1 =Armstrong  |first2 = Alex |    last2 =  Wayne  |url=https://www.bloomberg.com/news/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law.html | archive-url = https://web.archive.org/web/20160313090332/https://www.bloomberg.com/news/articles/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law  | archive-date  = March 13, 2016  |website =Bloomberg |title=Romneycare's 98% Success Rate Defies Gripes on Obama Law |date=March 26, 2012}}</ref>]]

=== Academic foundation ===

The concept of comparing the effectiveness of healthcare options based on hard data ("comparative effectiveness" and "evidence-based medicine") was pioneered by John E. Wennberg, founder of [[The Dartmouth Institute for Health Policy and Clinical Practice|The Dartmouth Institute]], co-founder of The Foundation for Informed Medical Decision Making and senior advisor to Health Dialog Inc., a venture that he and his researchers created to help insurers implement the Dartmouth findings.

A 2017 study found that the ACA reduced socioeconomic disparities in health care access.<ref>{{Cite journal |last1=Griffith |first1=Kevin |last2=Evans |first2=Leigh |last3=Bor |first3=Jacob |date=August 1, 2017 |title=The Affordable Care Act Reduced Socioeconomic Disparities In Health Care Access |journal=Health Affairs |volume=36 |issue=8 |pages=1503–1510 |doi=10.1377/hlthaff.2017.0083 |pmid=28747321 |pmc=8087201 |publisher=Project HOPE |oclc=07760874 |issn=0278-2715}}</ref>

===Taxes===

A 2016 study found that residents of Kentucky and Arkansas, which both expanded Medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period.<ref name="Sommers"/><ref>{{Cite magazine |last=Rutkin |first=Aviva |url=https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans|magazine=New Scientist |title=Obamacare has already improved health of low-income Americans |archive-url=https://web.archive.org/web/20160920082511/https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans |archive-date=September 20, 2016 |publisher=Reed Elsevier |location=London |access-date=June 21, 2022}}</ref> Kentucky opted for increased managed care, while Arkansas subsidized private insurance. Later Arkansas and Kentucky governors proposed reducing or modifying their programs. From 2013 to 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas.<ref name="Sommers">{{cite journal |last2=Blendon |last3=Orav |last4=Epstein |first2=Robert J. |first3=E. John |first4=Arnold M. |last1=Sommers |first1=Benjamin D. |title=Changes in utilization and health among low-income adults after medicaid expansion or expanded private insurance |journal=JAMA Internal Medicine |date=October 2016 |volume=176 |issue=10 |pages=1501–1509 |doi=10.1001/jamainternmed.2016.4419 |pmid=27532694 |url=https://jamanetwork.com/journals/intemed/articlepdf/2542420/ioi160066.pdf |archive-url=https://web.archive.org/web/20220621144827if_/https://jamanetwork.com/journals/intemed/articlepdf/2542420/ioi160066.pdf |archive-date=21 June 2022 |access-date=21 June 2022 |publisher=American Medical Association |s2cid=7874611 |issn=2168-6114}}</ref><ref>{{Cite web |url=https://www.hsph.harvard.edu/news/press-releases/medicaid-expansion-aca-lbetter-health-care-improved-health-low-income-adults/ |title=Medicaid expansion under ACA linked with better health care, improved health for low-income adults |publisher=Harvard T.H. Chan School of Public Health |website=www.hsph.harvard.edu |access-date=August 30, 2016 |date=August 8, 2016 |archive-date=February 23, 2021 |archive-url=https://web.archive.org/web/20210223181609/https://www.hsph.harvard.edu/news/press-releases/medicaid-expansion-aca-lbetter-health-care-improved-health-low-income-adults/ |url-status=live }}</ref>

In September 2019, the Census Bureau reported that states that expanded Medicaid under the ACA had considerably lower uninsured rates than states that did not. For example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid.<ref name="Census_2018">{{Cite web |url=https://www.census.gov/library/publications/2019/demo/p60-267.html |title=Health Insurance Coverage in the United States: 2018 |date=September 10, 2019 |access-date=September 13, 2019 |archive-date=March 21, 2021 |archive-url=https://web.archive.org/web/20210321163104/https://www.census.gov/library/publications/2019/demo/p60-267.html |url-status=live }}</ref> The drop in uninsured rates due to expanded Medicaid has broadened access to care among low-income adults, with post-ACA studies indicating an improvement in affordability, access to doctors, and usual sources of care.<ref name="ACA_low_income" />

|June 2023 (expected)

|[[HealthCare.gov]]

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|{{Flag|Ohio}}

Dependent Coverage Expansion (DCE) under the ACA has had a demonstrable effect on various health metrics of young adults, a group with a historically low level of insurance coverage and utilization of care.<ref name="ACA_DCE_2017" /> Numerous studies have shown the target age group gained private health insurance relative to an older group after the policy was implemented, with an accompanying improvement in having a usual source of care, reduction in out-of-pocket costs of high-end medical expenditures, reduction in frequency of Emergency Department visits, 3.5% increase in hospitalizations and 9% increase in hospitalizations with a psychiatric diagnosis, 5.3% increase in utilizing specialty mental health care by those with a probable mental illness, 4% increase in reporting excellent mental health, and a 1.5-6.2% increase in reporting excellent physical health.<ref name="ACA_DCE_2017" /> Studies have also found that DCE was associated with improvements in cancer prevention, detection, and treatment among young adult patients.<ref name="ACA_cancer_10yr" /><ref name="ACA_cancer_YA" /> A study of 10,010 women aged 18–26 identified through the 2008-12 National Health Interview Survey found that the likelihood of HPV vaccination initiation and completion increased by 7.7 and 5.8 percentage points respectively when comparing before and after October 1, 2010.<ref name="ACA_cancer_YA" /> Another study using National Cancer Database (NCDB) data from 2007 to 2012 found a 5.5 percentage point decrease in late-stage (stages III/IV) cervical cancer diagnosis for women aged 21–25 after DCE, and an overall decrease of 7.3 percentage points in late-stage diagnosis compared to those aged 26–34.<ref name="ACA_cancer_10yr" /> A study using SEER Program data from 2007 to 2012 found a 2.7 percentage point increase in diagnosis at stage I disease for patients aged 19–25 compared with those aged 26–34 for all cancers combined.<ref name="ACA_cancer_10yr" /> Studies focusing on cancer treatment after DCE found a 12.8 percentage point increase in the receipt of fertility-sparing treatment among cervical cancer patients aged 21–25 and an overall increase of 13.4 percentage points compared to those aged 26–34, as well as an increased likelihood that patients aged 19–25 with stage IIB-IIIC colorectal cancer receive timely adjuvant chemotherapy compared to those aged 27–34.<ref name="ACA_cancer_10yr" />

A 2020 ''JAMA'' study found that Medicare expansion under the ACA was associated with reduced incidence of advanced-stage breast cancer, indicating that Medicaid accessibility led to early detection of breast cancer and higher survival rates.<ref>{{Cite journal |last1=Blanc |first1=Justin M. Le |last2=Heller |first2=Danielle R. |last3=Friedrich |first3=Ann |last4=Lannin |first4=Donald R. |last5=Park |first5=Tristen S. |date=2020-07-01 |title=Association of Medicaid Expansion Under the Affordable Care Act With Breast Cancer Stage at Diagnosis |journal=JAMA Surgery |volume=155 |issue=8 |pages=752–758 |doi=10.1001/jamasurg.2020.1495 |pmid=32609338 |issn=2168-6262 |publisher=American Medical Association |pmc=7330827}}</ref> Recent studies have also attributed to Medicaid expansion an increase in use of smoking cessation medications, cervical cancer screening, and colonoscopy, as well as an increase in the percentage of early-stage diagnosis of all cancers and the rate of cancer surgery for low-income patients.<ref name="medicaid_cancer_continu" /><ref>{{cite journal |title=Impact of the Affordable Care Act on Colorectal Cancer Outcomes: A Systematic Review |year=2020 |doi=10.1016/j.amepre.2019.11.018 |last1=Xu |first1=Michelle R. |last2=Kelly |first2=Amanda M.B. |last3=Kushi |first3=Lawrence H. |last4=Reed |first4=Mary E. |last5=Koh |first5=Howard K. |last6=Spiegelman |first6=Donna |journal=American Journal of Preventive Medicine |volume=58 |issue=4 |pages=596–603 |pmid=32008799 |pmc=7175922}}</ref> These studies include a 2.1% increase in the probability of smoking cessation in Medicaid expansion states compared to non-expansion states, a 24% increase in smoking cessation medication use due to increased Medicaid-financed smoking cessation prescriptions, a 27.7% increase in the rate of colorectal cancer screening in Kentucky following Medicaid expansion with an accompanying improvement in colorectal cancer survival, and a 3.4% increase in cancer incidence following Medicaid expansion that was attributed to an increase in early-stage diagnoses.<ref name="medicaid_cancer_continu" />

The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200&nbsp;billion from 2010 to 2019.<ref>{{cite web |url=http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |title=Sen. Tom Coburn: Obamacare PR campaign anchored in spin, not reality |work=The Washington Examiner |date=July 8, 2006 |access-date=April 1, 2012 |url-status=dead |archive-url=https://archive.today/20120717095633/http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |archive-date=July 17, 2012 }}</ref><ref>{{cite news |url=http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta |title=Obamacare's Cooked Books and the 'Doc Fix{{'-}} |work=National Review |author=James Capretta |access-date=December 2, 2010 |archive-date=December 23, 2010 |archive-url=https://web.archive.org/web/20101223073630/http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta |url-status=live }}</ref><ref>{{cite web |last=Hogberg |first=David |url=http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |title=GOP Might Target ObamaCare As Part Of A Medicare 'Doc Fix' |work=Investor's Business Daily |date=November 22, 2010 |access-date=April 1, 2012 |archive-url=https://web.archive.org/web/20110126045757/http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |archive-date=January 26, 2011 |url-status=dead }}</ref> However, the so-called "[[Medicare Sustainable Growth Rate|doc fix]]" is a separate issue that would have existed with or without ACA.<ref>{{cite web |url=http://www.cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |title=Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010 |publisher=Congressional Budget Office |date=March 19, 2010 |access-date=April 1, 2012 |archive-date=February 20, 2012 |archive-url=https://web.archive.org/web/20120220015958/http://cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |url-status=live }}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |title=The Doc Fix Myth And The Right's Misinformation Feedback Loop |magazine=[[The New Republic]] |date=March 24, 2010 |access-date=March 10, 2017 |archive-date=September 12, 2015 |archive-url=https://web.archive.org/web/20150912112258/http://www.newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |url-status=live }}</ref><ref>{{cite web |last=Van de Water |first=Peter |title=Debunking False Claims About Health Reform, Jobs, and the Deficit |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3366 |publisher=Center for Budget and Policy Priorities |date=January 7, 2011 |access-date=March 12, 2012 |archive-date=March 12, 2012 |archive-url=https://web.archive.org/web/20120312164824/http://www.cbpp.org/cms/index.cfm?fa=view&id=3366 |url-status=live }}</ref> The [[Center on Budget and Policy Priorities]] objected that Congress had 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&nbsp;years to produce Medicare savings, although not the doc fix.<ref>{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |title=Congress Has Good Record of Implementing Medicare Savings |publisher=CBPP |access-date=March 28, 2010 |date=December 4, 2009 |archive-date=March 24, 2010 |archive-url=https://web.archive.org/web/20100324181543/http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |url-status=live }}</ref><ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |newspaper=[[The Washington Post]] |access-date=March 28, 2010 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308083159/http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |url-status=dead }}</ref> The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.<ref>Klein, Ezra. (June 26, 2010). "[https://web.archive.org/web/20121009120836/http://voices.washingtonpost.com/ezra-klein/2010/06/what_to_do_about_the_doc_fix.html What to do about the doc fix?]" ''Wonkbook'', The Washington Post. Archived (Blog) at the [https://web.archive.org/web/20121009120836/http://voices.washingtonpost.com/ezra-klein/2010/06/what_to_do_about_the_doc_fix.html Wayback Machine] on October 9, 2012. {{ISSN|0190-8286}} {{OCLC|2269358}}. Accessed July 27, 2011.</ref>

Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from [[Preventive medicine|preventive healthcare]], and that the CBO had a track record of overestimating costs and underestimating savings of health legislation;<ref name="CBOMethodology" /><ref name="CBOTrackRecord" /> stating, "innovations in the delivery of medical care, like greater use of [[electronic medical record]]s<ref>{{Cite web |url=https://www.medicalrecords.com/emr-buyers-guide/electronic-medical-records-deadline |title=Electronic Medical Records Deadline |website=MedicalRecords.com |access-date=July 24, 2019 |archive-date=March 9, 2021 |archive-url=https://web.archive.org/web/20210309013837/https://www.medicalrecords.com/emr-buyers-guide/electronic-medical-records-deadline |url-status=live }}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses{{nbsp}}... 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."<ref name="CBOMethodology" />

In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved.<ref>{{cite web |url=http://www.cbsnews.com/news/poll-obamacare-and-the-supreme-court/ |title=Poll: Obamacare and the Supreme Court |work=[[CBS News]] |date=June 22, 2015 |access-date=June 23, 2015 |archive-date=December 1, 2020 |archive-url=https://web.archive.org/web/20201201040030/https://www.cbsnews.com/news/poll-obamacare-and-the-supreme-court/ |url-status=live }}</ref> A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.<ref>{{cite web |url=http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/ |title=After the Election, the Public Remains Sharply Divided on Future of the Affordable Care Act |publisher=[[Kaiser Family Foundation]] |date=December 3, 2016 |access-date=December 3, 2016 |archive-date=February 25, 2021 |archive-url=https://web.archive.org/web/20210225032025/https://www.kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/ |url-status=live }}</ref>

By the end of 2023, a Morning Consult poll of registered voters found that 57% approved of the Affordable Care Act, while 30% disapproved of it. 85% of Democrats, 56% of independents, and 28% of Republicans supported the law.<ref>{{cite news |url=https://pro.morningconsult.com/analysis/obamacare-polling-popularity |title=Obamacare Has Become Even More Popular Over Biden's Presidency |date=December 6, 2023 |publisher=[[Morning Consult]] |access-date=January 11, 2024 |archive-date=January 11, 2024 |archive-url=https://web.archive.org/web/20240111192353/https://pro.morningconsult.com/analysis/obamacare-polling-popularity |url-status=live }}</ref>

==Criticism and opposition==

{{As of|2013}} unions that expressed concerns included the [[AFL–CIO]],<ref name="AFLCIO" /> which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the [[International Brotherhood of Teamsters]], [[United Food and Commercial Workers International Union]], and [[UNITE-HERE]], whose leaders sent a letter to Reid and Pelosi arguing, "PPACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class."<ref name="WSJ" /> In January 2014, Terry O'Sullivan, president of the [[Laborers' International Union of North America]] (LIUNA) and [[D. Taylor]], president of [[UNITE HERE|Unite Here]] sent a letter to Reid and Pelosi stating, "ACA, as implemented, undermines fair marketplace competition in the health care industry."<ref name="wapo" />

{{Main|Burwell v. Hobby Lobby Stores, Inc.|Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania}}

In ''[[Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania]]'', the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice [[Clarence Thomas]] said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the [administration], that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice [[Elena Kagan]] filed a concurring opinion in the judgment, in which [[Stephen Breyer]] joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."<ref>{{cite web |title=Supreme Court allows Trump to exempt employers from Obamacare birth control mandate |url=https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |archive-date=July 25, 2020 |archive-url=https://web.archive.org/web/20200725005137/https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |work=[[ABC News (United States)|ABC News]] |publisher=Walt Disney |access-date=June 18, 2022 |last1=Dwyer |first1=Devin}}</ref>

District Judge [[Reed O'Connor]] of Texas ruled for the plaintiffs on December 14, 2018, writing that the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional." He then further reasoned that the individual mandate is an essential part of the entire law, and thus was not severable, making the entire law unconstitutional.<ref>{{Cite web |last=Sullivan |first=Peter |date=December 14, 2018 |url=https://thehill.com/policy/healthcare/421511-federal-judge-in-texas-strikes-down-obamacare/ |title=Federal judge in Texas strikes down ObamaCare |website=[[The Hill (newspaper)|The Hill]] |issn=1521-1568 |oclc=31153202 |access-date=December 15, 2018 |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215013835/https://thehill.com/policy/healthcare/421511-federal-judge-in-texas-strikes-down-obamacare |url-status=live }}</ref><ref>{{Cite web |url=https://www.wsj.com/articles/federal-judge-rules-affordable-care-act-is-unconstitutional-11544838743 |title=Federal Judge Rules Affordable Care Act Is Unconstitutional Without Insurance-Coverage Penalty |last=Armour |first=Stephanie |date=December 14, 2018 |publisher=News Corp |oclc=781541372 |issn=0099-9660 |website=[[The Wall Street Journal]] |access-date=December 15, 2018 |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215043107/https://www.wsj.com/articles/federal-judge-rules-affordable-care-act-is-unconstitutional-11544838743 |url-status=live }}</ref> O'Connor's decision regarding severability turned on several passages from the Congressional debate that focused on the importance of the mandate.<ref>{{Cite web |url=https://lawshelf.com/blog/post/federal-judge-in-texas-strikes-down-obamacare |title=Federal Judge in Texas Strikes Down "Obamacare" |website=lawshelf.com |access-date=May 14, 2019 |archive-date=May 14, 2019 |archive-url=https://web.archive.org/web/20190514121812/https://lawshelf.com/blog/post/federal-judge-in-texas-strikes-down-obamacare |url-status=live }}</ref> While he ruled the law unconstitutional, he did not overturn the law.<ref name="cnn 20181214">{{cite web |url=https://www.cnn.com/2018/12/14/politics/texas-aca-lawsuit/index.html |title=Federal judge in Texas strikes down Affordable Care Act |first1=Ariane |last1=de Vogue |first2=Tami |last2=Luhby |date=December 14, 2018 |access-date=December 14, 2018 |publisher=[[CNN]] |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215021340/https://www.cnn.com/2018/12/14/politics/texas-aca-lawsuit/index.html |url-status=live }}</ref>

Democrats pointed out that the effect of invalidating the entire law would be to remove popular provisions such as the protection for preexisting conditions, and that the Republicans had still not offered any replacement plan—important issues in the 2020 elections.<ref name="ollstein" />

====2013 federal government shutdown====

Republicans attempted to defund the ACA's implementation,<ref name="Ornstein" /><ref>{{cite news |first=Jonathan |last=Cohn |title=What Defunding Health Reform Would Do |url=https://newrepublic.com/blog/jonathan-cohn/80411/what-defunding-health-reform-would-do |magazine=[[The New Republic]] |date=December 23, 2010 |access-date=March 10, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013001/https://newrepublic.com/article/80411/what-defunding-health-reform-would-do |url-status=live }}</ref> and in October 2013 House Republicans refused to fund the federal government unless it came with an implementation delay, after Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay the ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership said the Senate would pass only a bill without any restrictions on ACA. [[United States federal government shutdown of 2013|The government shutdown]] lasted from October 1 to October 17.<ref>{{cite news |issn=0190-8286 |oclc=2269358 |archive-date=October 1, 2013 |archive-url=https://web.archive.org/web/20131001122124/https://www.washingtonpost.com/politics/washington-braces-for-the-first-shutdown-of-the-national-government-in-17-years/2013/09/30/977ebca2-29bd-11e3-97a3-ff2758228523_story.html |url=https://www.washingtonpost.com/politics/washington-braces-for-the-first-shutdown-of-the-national-government-in-17-years/2013/09/30/977ebca2-29bd-11e3-97a3-ff2758228523_story.html |title=Shutdown begins: Stalemate forces first U.S. government closure in 17 years |newspaper=[[The Washington Post]] |date=October 1, 2013 |access-date=June 21, 2022 |author1=Montgomery, Lori |author2=Kane, Paul }}<br />{{cite news |url=https://www.washingtonpost.com/blogs/post-politics/wp/2013/09/19/mccain-efforts-to-repeal-and-defund-obamacare-not-rational |title=McCain: Efforts to repeal and defund Obamacare 'not rational{{'-}} |newspaper=[[The Washington Post]] |date=September 19, 2013 |issn=0190-8286 |oclc=2269358 |author=Blake, Aaron |access-date=September 24, 2013 |archive-date=March 12, 2016 |archive-url=https://web.archive.org/web/20160312235114/https://www.washingtonpost.com/blogs/post-politics/wp/2013/09/19/mccain-efforts-to-repeal-and-defund-obamacare-not-rational |url-status=live }}</ref><ref name="Beutler" /><ref>{{cite news |first=Jonathan |last=Cohn |title=Tea Party to Republicans: Shut Down the Government, or You're a Sellout |url=https://newrepublic.com/article/114229/tea-party-wants-government-shutdown-over-obamacare |magazine=[[The New Republic]] |date=August 7, 2013 |access-date=March 10, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013007/https://newrepublic.com/article/114229/tea-party-wants-government-shutdown-over-obamacare |url-status=live }}</ref>

{{Main|2017 Patient Protection and Affordable Care Act replacement proposals}}

[[File:John McCain Votes No on Obamacare Repeal.jpg|left|thumb|McCain votes no on repealing the Affordable Care Act by giving a thumbs down.]]

On May 4 the House voted to pass the AHCA by a margin of 217 to 213.<ref>{{cite news |url=http://edition.cnn.com/2017/05/04/politics/health-care-vote/ |title=House Republicans pass bill to repeal and replace Obamacare |publisher=[[CNN]] |date=May 4, 2017 |access-date=May 4, 2017}}</ref> The Senate Republican leadership announced that Senate Republicans would write their own version of the bill instead of voting on the House version.<ref>{{Cite web |url=https://www.businessinsider.com/senate-plan-for-healthcare-bill-ahca-2017-5 |title=Senate Republicans signal they plan to scrap bill the House just passed and write their own |first=Bob |last=Bryan |website=[[Business Insider]] |date=May 4, 2017}}</ref>

The revised BCRA failed, 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but that too failed, 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to ACA, failed by 49–51, with Collins, Murkowski, and McCain joining all Democrats and independents in voting against it.<ref>{{Citation |last=Klein |first=Ezra |author-link=Ezra Klein |title=The GOP's massive health care failures, explained |publisher=[[Vox (website)|Vox]] |date=July 28, 2017 |url=https://www.vox.com/health-care/2017/7/28/16055284/gop-massive-health-care-failures-explained |archive-url=https://web.archive.org/web/20170728212507/https://www.vox.com/health-care/2017/7/28/16055284/gop-massive-health-care-failures-explained |archive-date=July 28, 2017 |access-date=August 3, 2017}}</ref>

===Actions to hinder implementation===

* Lawsuits such as ''[[King v. Burwell]]'' and ''[[House v. Price]]''.  

* President Trump ended the payment of [[Cost sharing reductions subsidy|cost-sharing reduction]] subsidies to insurers on October 12, 2017. CBO estimated in September 2017 that discontinuing the payments would add an average of 15–20 percentage points to health insurance costs on the exchanges in 2018 while increasing the budget deficit nearly $200 billion over a decade.<ref name="VoxCBO1">{{Cite web |url=https://www.vox.com/policy-and-politics/2017/9/14/16308502/cbo-trump-obamacare-premiums |title=CBO: Trump is making Obamacare premiums more expensive |first=Sarah |last=Kliff |date=September 14, 2017 |website=[[Vox (website)|Vox]]}}</ref> In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019.<ref name=":3" /> Several insurers and actuarial groups estimated this resulted in a 20 percentage point or more increase in premiums for the 2018 plan year. In other words, premium increases expected to be 10% or less in 2018 became 28–40% instead.<ref>Scott, Dylan (October 18, 2017). [https://www.vox.com/policy-and-politics/2017/10/18/16458316/obamacare-premiums-trump "Obamacare premiums were stabilizing. Then Trump happened"]. Vox.</ref><ref>Kliff, Sarah. (October 18, 2017). [https://www.vox.com/health-care/2017/10/18/16499806/trump-insurance-bailouts-completely-incoherent "Trump's stance on insurance 'bailouts' is completely incoherent"]. ''Vox''. Archived at [https://web.archive.org/web/20171108211628/https://www.vox.com/health-care/2017/10/18/16499806/trump-insurance-bailouts-completely-incoherent Wayback Machine] on November 8, 2017.</ref> The insurers would need to make up the $7 billion they had previously received in cost-sharing reductions (CSRs) by raising premiums. Since most premiums are subsidized, the federal government would cover most of the increases. CBO also estimated that initially up to one million fewer people would have health insurance coverage, although rising subsidies might eventually offset this. The 85% of enrollees who received subsidies would be unaffected. CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level.<ref>Congressional Budget Office. (August 15, 2017). [https://www.cbo.gov/publication/53009 "The Effects of Terminating Payments for Cost-Sharing Reductions"]. Archived at [https://web.archive.org/web/20171016113108/https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53009-costsharingreductions.pdf Wayback Machine] on October 16, 2017.</ref> Several insurance companies who sued the United States for failure to pay CSRs won cases in 2018 and 2019. The judiciary decided the insurance companies are entitled to unpaid CSRs.<ref name=":3"/><ref>{{cite journal |last1=Keith |first1=Katie |title=Insurer Wins First CSR Payment Decision; Updates On BHP And Risk Corridors Litigation |url=https://www.healthaffairs.org/do/10.1377/forefront.20180906.295628/full/ |journal=Health Affairs |date=September 6, 2018 |doi=10.1377/forefront.20180906.295628}}</ref>

* Trump weakened the individual mandate with his first executive order, which limited enforcement of the tax. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding Obama's instructions to reject them.<ref>{{Cite web |url=https://www.politico.com/story/2017/05/03/trump-obamacare-mandate-enforcement-237937 |title=Trump still enforcing Obamacare mandate |first1=Brianna |last1=Ehley |first2=Aaron |last2=Lorenzo |website=[[Politico]]|date=May 3, 2017 }}</ref>

* Trump reduced funding for advertising for exchange enrollment by up to 90%, with other reductions to support resources used to answer questions and help people sign-up for coverage.<ref>{{Cite web |url=https://www.vox.com/2017/8/31/16236280/trump-obamacare-outreach-ads |title=Trump is slashing Obamacare's advertising budget by 90% |first=Sarah |last=Kliff |date=August 31, 2017 |website=[[Vox (website)|Vox]]}}</ref> The CBO said the reductions would reduce ACA enrollment.<ref name="VoxCBO1" />

* Trump made public statements that the exchanges were unstable or in a [[death spiral (insurance)|death spiral]].<ref>{{Cite web |url=https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |first1=Louise |last1=Norris |access-date= |archive-date=November 18, 2017 |archive-url=https://web.archive.org/web/20171118012524/https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |title=10 ways the GOP sabotaged Obamacare |date=May 17, 2017 |website=healthinsurance.org}}</ref>

{{Main|Implementation history of the Patient Protection and Affordable Care Act}}

The [[Government Accountability Office]] released a non-partisan study in 2014 that concluded the administration had not provided "effective planning or oversight practices" in developing the exchanges.<ref name="AP-20140731" /> In ''[[Burwell v. Hobby Lobby]]'' the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.<ref name=":2" /> At the beginning of the 2015, 11.7 million had signed up (ex-Medicaid).<ref>{{Cite news |url=https://www.bloomberg.com/news/articles/2015-06-02/obamacare-dropouts-lead-to-enrollment-decline-of-1-5-million |title=Obamacare Sign-Ups Decline to 10.2 Million as Some Don't Pay |last=Tracer |first=Zachary |website=Bloomberg.com |date=June 2, 2015 |access-date=August 21, 2016}}</ref> By the end of the year about 8.8 million consumers had stayed in the program.<ref>{{Cite web |url=https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-11.html |title=December 31, 2015 Effectuated Enrollment Snapshot |date=March 11, 2016 |access-date=June 18, 2022 |archive-date=April 11, 2016 |archive-url=https://web.archive.org/web/20160411120015/https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-11.html |location=Baltimore, MD |publisher=Health and Human Services |website=cms.gov}}</ref> Congress repeatedly delayed the onset of the "[[Cadillac tax]]" on expensive insurance plans first until 2020<ref>{{Cite web |url=http://www.politico.com/story/2015/12/white-house-obamacare-cadillac-tax-216881 |title=How the White House lost on the Cadillac Tax |last=COOK |first=NANCY |date=December 16, 2015 |publisher=[[Politico]]|access-date=August 21, 2016}}</ref> and later until 2022 and repealed it in late 2019.<ref name="auto1"/>

An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults. The five major national insurers expected to lose money on ACA policies in 2016,<ref>{{Cite news |url=https://www.wsj.com/articles/aetna-to-drop-some-affordable-care-act-markets-1471311737 |title=Aetna to Drop Some Affordable Care Act Markets |last=Mathews |first=Anna Wilde |date=August 16, 2016 |newspaper=[[The Wall Street Journal]]|publisher=News Corp |oclc=781541372 |issn=0099-9660 |access-date=August 16, 2016}}</ref> in part because the enrollees were lower income, older and sicker than expected.<ref>{{Cite news |url=https://www.wsj.com/articles/the-unstable-economics-in-obamas-health-law-1471452938 |title=The Unstable Economics in Obama's Health Law |last=Ip |first=Greg |date=August 17, 2016 |newspaper=[[The Wall Street Journal]] |issn=0099-9660 |access-date=August 23, 2016}}</ref>

By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicaid or via an alternative program.<ref>{{Cite web |archive-date=November 20, 2013 |archive-url=https://web.archive.org/web/20131120111501/https://www.advisory.com/daily-briefing/resources/primers/medicaidmap |url=https://www.advisory.com/daily-briefing/resources/primers/medicaidmap |work=Daily Briefing |title=Where the states stand on Medicaid expansion |publisher=The Advisory Board |access-date=June 18, 2022 |date=February 6, 2019}}</ref>

<ref name="NYMagChait2">{{cite news |url=http://nymag.com/daily/intelligencer/2013/05/yuval-levin-dissembles-madly.html |title=Yuval Levin Dissembles Madly |last=Chait |first=Jonathan |date=May 29, 2013 |work=[[New York (magazine)|New York Intelligencer]]}}</ref>

<ref name="ObamaPromise">{{cite web |first=Louis |last=Jacobson |title=Barack Obama says that what he'd said was you could keep your plan 'if it hasn't changed since the law passed{{'-}} |url=http://www.politifact.com/truth-o-meter/statements/2013/nov/06/barack-obama/barack-obama-says-what-hed-said-was-you-could-keep/ |publisher=[[PolitiFact]]|access-date=November 9, 2013}}</ref>

<ref name="SchiffHardinLLP">{{cite web |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |title=Next Steps to Comply with Health Care Reform |date=October 10, 2012 |work=The National Law Review |access-date=October 10, 2012}}</ref>

<ref name="Sep2009JointAddress">{{cite web |url=https://obamawhitehouse.archives.gov/the-press-office/remarks-president-a-joint-session-congress-health-care |title=Remarks by the President to a Joint Session of Congress on Health Care |date=September 10, 2009 |access-date=March 24, 2010 |url-status=live |archive-url=https://web.archive.org/web/20170126012951/https://obamawhitehouse.archives.gov/the-press-office/remarks-president-a-joint-session-congress-health-care |via=[[NARA|National Archives]] |work=[[whitehouse.gov]] |archive-date=January 26, 2017}}</ref>