Patient Protection and Affordable Care Act

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Barack Obama signs the Care Act on March 23, 2010

The Patient Protection and Affordable Care Act ( PPACA ) is a federal law of the United States . It was passed by the US Congress at the instigation of the Obama administration in 2010, the second year of President Barack Obama's administration , and is therefore often referred to as Obamacare . The PPACA regulates access to health insurance , among other things, and is considered an essential part of the current US health system .

The law and the Health Care and Education Reconciliation Act , enacted a few days later , which modified it slightly, have been highly controversial legally and politically, and the controversy continues after its passage and entry into force. The Supreme Court of the United States upheld the law in its ruling on the National Federation of Independent Business v. Sebelius on June 28, 2012 almost completely. As of April 1, 2014, the previously planned number of new insured persons was achieved due to the law.

The Republican Party announced over the years that it would repeal and replace the law. Since the election of President Donald Trump , however, all initiatives to abolish or reform the PPACA have failed due to disagreement among the party wings.

Contents of the law

The PPACA includes numerous individual regulations that come into force over several years in order to create sufficiently long transition periods for both health insurers and patients. The core of the law is the so-called individual mandate , according to which every American is obliged to take out health insurance if he is not otherwise covered, in particular by his employer. There are exceptions for members of a few religious groups and there is a hardship clause to cover people who are not covered by Medicaid because of their poverty but cannot afford insurance. This is offset by the insurance company’s obligation to accept every patient and not to make the insurance dependent on a health check and the lack of information on previous illnesses.

Services

A core performance ( Essential Health Benefits ) has been introduced for all insurances, for which neither spending caps nor additional payments are permitted. Additional payments must be made for benefits beyond this, the percentage of which depends on which standardized benefit package (bronze, silver, gold, platinum) the insured person has chosen. Most US states had set up comparison portals on the Internet by the end of 2013, on which all insurance carriers licensed in the respective state must transparently present their premiums and services on November 15 each year and on which every citizen, after entering his data, the cheapest provider of the packages Bronze, silver and gold are displayed. For residents of those countries that do not set up comparison portals, the federal government created a central portal under healthcare.gov. Citizens who have not yet been insured can then register between November 15 and December 15 for insurance from January 1 of the following year. Tax benefits and subsidies are only available to citizens who take out insurance through one of the official portals.

Companies with more than 50 employees must either offer their employees at least bronze-level insurance or contribute to the financing of the reform through a tax. Very small businesses can get grants for certain group insurance policies.

The federal government is extending Medicaid to all people whose income is below the federal government's definition of poverty. The individual states can decide that their citizens have access to discounts for health insurance between 100% and 400% of the poverty line, the subsidies are paid by the federal government. 25 countries have decided against an extension because of their fundamental rejection of the health reform. They are all ruled by a Republican majority. These states also do not take part in the comparison portals, so a website of the federal government was set up for their citizens.

Uninsured persons who are not subject to any of the exemptions must pay the equivalent of their insurance premiums to the federal government from 2015 . This regulation is intended to ensure the enforcement of compulsory insurance and was the core of the legal disputes over the PPACA. The Supreme Court ruled that such an obligation was inadmissible as a punitive regulation, but reinterpreted it as a tax under the constitutional interpretation and declared it permissible. A clause under which US states that fail to meet certain obligations under the law would lose all federal grants to Medicaid was declared inadmissible by the Supreme Court as the only part of the legislative package and removed.

financing

To finance the expansion of benefits, a new tax of 3.8% was levied on interest income and dividend income and a surcharge of 0.9% on income tax for taxable annual income of $ 200,000 or more. For low-income insured persons, new insurance grants will be introduced and existing ones will be increased. In addition, the existing program, which insures children of low-income families, is being expanded considerably. These subsidies are staggered based on income and expire depending on the number of dependent family members with an annual income between 40,000 and 50,000 dollars.

Within the insurance companies, young and healthy insured persons subsidize older insured persons and those with chronic illnesses who incur higher expenses. Experience shows that tax surcharges and cross-subsidization within insurance tariffs will be sufficient until mid-2017 to cover the expansion of benefits. However, they do not cover the expansion of those eligible for Medicare, even though many states do not support the expansion, including Texas, the second largest state in the United States.

Legislative process

prehistory

President Obama's campaign program

Barack Obama had rejected compulsory health insurance in his election manifesto. He only wanted an exception for the children: in the future, all of them should be insured without exception. It is reasonable for parents to have their children insured, since health insurance for children is very cheap. However, since some parents are still unable to pay for insurance for their children, the State Children's Health Insurance Program (SCHIP) should be expanded.

Barack Obama at a campaign event (2008)

However, the number of uninsured people should be reduced by expanding government aid programs and financial incentives as well as new guidelines:

  1. The introduction of new tax credits should make it easier for small businesses to provide health insurance to their workers and employees.
  2. At the same time, larger companies that offer their workers little or no health insurance coverage should be (compulsorily) involved in the financing of the public health system through a kind of payroll tax .
  3. In the future, health insurers should be prohibited from referring to previous illnesses , so-called pre-existing conditions . Given this justification, they should no longer be able to refuse payments or increase contributions.

In addition, Obama wanted to introduce state health insurance as a complement to private health insurance in line with the public-private model. This was similar to Medicare, but should be aimed at people who are not yet 65 years old. The target group should be primarily those people who cannot obtain health insurance from their employer and who are not already insured through Medicaid or SCHIP.

Alternative legislative proposals in Congress

Opponents of health reform in West Hartford on September 2, 2009
Healthcare reform advocate in Seattle on September 3, 2009
President Barack Obama's speech on health system reform on September 9, 2009 to Congress

In Congress in 2009, some legislative proposals submitted for reform of the health system.

The United States National Health Care Act was introduced by Democratic MP John Conyers . According to this bill, Medicare should be expanded into a general state health insurance that covers all citizens (Universal Single-Payer Healthcare). Private health insurance would then no longer have been needed; the insurance costs would have been financed through taxes, as with Medicare. The Canadian health system was the model for the reform proposal.

The Healthy Americans Act , submitted by Democratic Senator Ron Wyden and Republican Senator Bob Bennett , aimed to require all citizens to take out health insurance (National Health Insurance). However, there should still be various state and private health insurances, so a single-payer model was not considered here. Medicaid and the State Children's Health Insurance Program should be liquidated. The previous system of employer-mediated group insurance should be abolished. They should be replaced by government-sponsored Healthy Americans Private Insurance Plans ; The insurance costs would have been paid through taxes, and the tax revenue would then have been distributed to the respective insurance company. The advantage would have been that the health insurance could have been retained if the employer had changed. The insurance conditions would have been defined uniformly by the government for all insurance companies. If this plan had been implemented, most citizens would have had higher health insurance costs than before. This would have been mitigated by the fact that the health insurance costs could have been deducted from income tax on a generous basis. For employers, the voluntary health insurance benefits to their employees would have ceased to exist, but they should have paid a special tax and increased their employees' wages.

Adoption of the 2010 health reform

Legislative proposal by the leadership of the Democratic Party

The America's Affordable Health Choices Act of 2009 was designed by John Dingell , Charles B. Rangel , Henry Waxman , George Miller , Pete Stark , Frank Pallone and Rob Andrews introduced. He represents the legislative proposal of the leadership of the Democratic Party . The bill takes up President Obama's reform plans.

Extremely violent protests on the part of the Conservatives followed the reform plans presented in America's Affordable Health Choices Act of 2009 . One accusation with great media impact was the repeated assertion that the reform would introduce “death panels”. The background was that in the extensive legislative proposal, a sub-item was intended to be an amendment to Section 1861 of the Social Security Act in such a way that Medicare patients could in future be informed at state expense, among other things, of their doctor about the (already existing) possibility of an advance directive . This idea was borrowed from a legislative initiative tabled by Republican Congressman Charles Boustany , the Life Sustaining Treatment Preferences Act of 2009 . The right-wing newspaper Investor's Business Daily said it saw a plan to fathom the will to live of elderly citizens who should be systematically urged to euthanize by their doctor . Ultimately, euthanasia is planned for the elderly and the sick. The paper drew a comparison with the UK's national health system, the National Health Service , claiming that people with severe disabilities such as famous scientist Stephen Hawking had no chance of survival there. The "death panel" argument has been taken up by many Republicans , especially former Republican candidate for Vice President Sarah Palin . Moderate Republicans opposed this strategy. Palin and others were criticized by the Republican Senator Lisa Murkowski : since there is no reason to intentionally stir up fear in the population about "death panels", which the America's Affordable Health Choices Act of 2009 does not provide at all, it should be better practice serious and objective criticism. Republican Charles Boustany noted that the discussion on the subject had unfortunately gotten out of hand. Stephen Hawking finally felt compelled to make it clear that he had lived in Great Britain since his birth and was only still alive at all because of the very good medical care provided by the National Health Service .

Furthermore, the option of a state health insurance was discussed controversially. There are fears that private health insurance companies could lose customers on a large scale and therefore have to lay off employees. The cost of the reform was also discussed, especially the situation of smaller companies that could not afford to insure their workers. There is also controversy over whether the proposed bill could result in illegal immigrants benefiting from health insurance as well. President Obama attempted to address existing concerns in a speech to Congress on September 9, 2009.

Legislative process in the House of Representatives and Senate

The House of Representatives passed the Affordable Health Care for America Act , the successor to America's Affordable Health Choices Act of 2009 , on November 8, 2009 .

Max Baucus , chairman of the Senate Finance Committee (center) and Chuck Grassley , member of the Finance Committee (left)

On September 13, 2009, the Senate Finance Committee approved America's Healthy Future Act, introduced by Senator Max Baucus . This largely corresponds to the reform plans of the leadership of the Democratic Party, but provides for state-regulated private-law health insurance instead of optional state health insurance. On November 21, the Senate voted with a Democratic majority to put the Patient Protection and Affordable Care Act , an advancement of America's Healthy Future Act , on the agenda for debate. On December 21, 2009 the Senate finally voted with the necessary 3/5 majority for a time limit for the debates, thereby preventing a filibuster . A vote on the draft law took place on December 24, 2009, and the proposed law was adopted with 60 to 39 votes.

As a further step, the Senate and the House of Representatives had to agree on a uniform bill. However, the Democrats lost their three-fifths majority in the Senate through a by-election. This gave the Republicans the opportunity to use filibusters to significantly delay the legislative process.

A path was therefore taken to avoid the possible blockade in the Senate. Accordingly, on March 21, 2010, the House of Representatives passed the Senate Patient Protection and Affordable Care Act by 219 votes to 212 , which became law. The Health Care and Education Affordability Reconciliation Act of 2010 contains the changes requested by the Democratic representatives in the House of Representatives to the Patient Protection and Affordable Care Act . In a second step, the Health Care and Education Affordability Reconciliation Act of 2010 was passed with 220 votes to 211 on the same day . The Senate met and voted on this law on March 25, 2010 in the reconciliation process , in which a filibuster is not possible. The Health Care and Education Affordability Reconciliation Act of 2010 was passed in the Senate with 56 votes to 43.

Legal disputes

Some organizations (such as the National Federation of Independent Business), parts of the Republican Party and some states had brought legal action against the health care reform. The main point of contention was the introduction of general compulsory insurance. On June 28, 2012, the Supreme Court of the United States ( National Federation of Independent Business v. Sebelius ) upheld the constitutionality of essential parts of the Patient Protection and Affordable Care Act . The Court of Justice denied Congress a competence that could be derived from the Commerce Clause of the constitution to oblige citizens to take out health insurance. However, the majority of judges interpreted the fine for (non-exempt) uninsured persons, which will become effective from 2014 when the health reform is passed, as a tax that is covered by the federal taxation authority. The court only denied constitutionality to one regulation provided for in the law: the federal government was not allowed to punish states with a lack of cooperation with the withdrawal of all Medicaid funds.

In June 2014, the Supreme Court ruled in the Hobby Lobby proceedings that certain - in particular owner-managed - employers can insist that individual contraception methods may be excluded from the health insurance offered to their employees for religious reasons. An exception, which the law has so far only provided for religious associations, is extended to them, according to which these benefits are taken over by the health insurances on their own account. This is possible without any negative effects for the insured women, because contraception means save insurance companies more expenses than they cost.

In 2015, the Supreme Court ruled that all Americans are entitled to the insurance premium subsidy, regardless of whether they live in a state that offers its own comparison portal or one that does not and whose citizens access the portal of the federal government. According to a controversial formulation in the wording of the law, plaintiffs had argued that only portals in one state would give access to subsidies. The Supreme Court rejected this interpretation by 6: 3 votes.

In May 2016, based on a lawsuit filed by the Republican majority faction, a federal court ruled that contrary to the opinion of the Obama administration , the PPACA would not include a federal budget allocation. Therefore, the federal government should not make any payments to the insurance companies with which contracts of socially disadvantaged insured persons are subsidized. The government appealed and the court suspended the decision. After Donald Trump took over government, his Ministry of Health announced that it would continue to pay all subsidies despite the decision.

Continuation of the political conflict

  • States where access to Medicaid has been expanded
  • States in which the political discussion is ongoing
  • States where access to Medicaid has not been expanded

    • The political debate continued after its adoption and also after it came into force. The Republican Party made the law a symbol of the confrontation with Obama and the Democrats. All of their attempts in Congress failed before the November 2014 election due to a democratic majority in the Senate . However, the Republicans in the House of Representatives prevented any amendment of the law, including the rectification of identified weaknesses. After the Republicans had won a majority in both houses in the 114th Congress of the United States , there was another attempt to veto President Obama in January 2016, which he had announced in this case .

    In the states where Republicans were in the majority, they in various ways prevented the implementation or success of health insurance. Without the expansion of Medicare, there would be no subsidies for the lower middle class, and lawsuits filed by Republicans would lead to insecurity in insurance and, as a result, to a lack of investment. In addition, Republicans repeatedly referred to an alleged imminent collapse of the system through rising premiums, almost exclusively affecting those states in which the Republican majority prevented the full application of the law.

    Republican majority since 2015

    The Republican candidate Mitt Romney , ultimately unsuccessful in the 2012 presidential election, wanted to repeal the law if he won. At the end of 2013, the Tea Party wing of the Republican Party in the House of Representatives used budget law as leverage. He declared that he would only agree to an emergency budget if all budget estimates for the insurance reform were canceled, i.e. the law would run dry. After the democratically dominated Senate and President Obama were not ready to negotiate, a 16-day government shutdown began on October 1, 2013 . On October 16, the Republicans had to give way in Congress and approve a budget. Public opinion had turned against them because they were blamed for the administrative deadlock.

    The political controversy continued in the individual states. The law provides generous federal funding to extend Medicaid benefits to citizens who have incomes up to 400% of the poverty line, depending on their income and number of family members. The prerequisite is that your respective state decides this extension by law. The majority of the Republican-governed states politically rejected the law completely and initially denied their citizens these federal services. Coercive measures in the law were the only part that was overturned by the Federal Supreme Court.

    In the years after the law was passed, and with the positive experience in states that expanded Medicaid, even strictly Republican states are turning away from the hardline position. Arizona , Arkansas , Indiana , Iowa , Michigan , Nevada , New Jersey , New Mexico, and Ohio all expanded Medicaid through late 2015. In South Dakota , Tennessee, and Utah , Republican governors advocated expansion, but parliaments opposed it. The Republican factions in the House of Representatives and the Senate see this split in the party line as a threat.

    Presidency Trump

    In the campaign leading up to the presidential election on November 8, 2016 , Donald Trump , the Republican Party and many Republican politicians made the ACA a campaign topic. Republicans retained their majority in both houses of Congress, and Trump was elected US President. In the constituent session of the 115th Congress , the Republican majority in the House of Representatives passed a financial resolution in early January 2017, which, in addition to general allocations, provides funds with which the legislature can draft new health legislation. In addition, the prerequisite was created so that the relevant legislation can pass the congress via the accelerated route of a reconciliation procedure . On the day of his inauguration, Trump issued an order to the health authorities to use all possibilities to reduce costs for insured persons, insurance companies and service providers; shortly thereafter he appointed Tom Price , a critic of the law, as Minister of Health in his cabinet . The general rejection of the ACA among Republicans hides large differences of opinion about which parts of the legislative package should be repealed and which should be preserved. Observers predict a process that will take several years, which could be determined by uncertainties such as the majority in the Senate.

    In early March 2017, six weeks after Trump took office, the Republican majority faction in the United States House of Representatives presented a bill to replace “Obamacare” with a new system. Compulsory insurance and subsidies from tax revenues are to be abolished. According to the Independent Budget Office of Congress (CBO), around 14 million people were at risk of losing health insurance in 2018. The American Health Care Act , which was supposed to be one of several steps to abolish and replace Obamacare, failed on March 24, 2017, after it became apparent that both moderate Republican MPs and ultra-conservative members of the Freedom Caucus were from various Reasons would reject the law and the bill would not have a majority, Speaker Paul Ryan did not put the bill to the vote.

    On May 4, 2017, after massive pressure from Trump and the parliamentary group leadership, 217 Republican MPs in the House of Representatives voted for a slightly amended version of the American Health Care Act , while 213 Democrats and Republicans voted against. The Senate refused to discuss the House of Representatives draft and planned to create a completely new version. The leadership of the Republican Party, contrary to its own traditions and principles, did not wait for the CBO to calculate how the plan would affect the budget and how many Americans could lose their insurance policies as a result of the law. On May 24, 2017, the CBO came to the conclusion that with the draft law, 14 million people insured under ACA would lose their protection in 2018, 19 million by 2020 and 23 million by 2026. The savings of the federal budget would amount to 119 billion dollars over ten years , far less than hoped, and predominantly affect the top 5 percent of incomes.

    A new draft presented by the Senate in June 2017 interfered with the guarantees that insured persons may not be discriminated against because of previous illnesses. It allows insurers to deviate from the core services of essential health benefits and to offer tariffs that do not include benefits for medication or other mandatory benefits under the ACA. Young and healthy insured persons could switch to these cheaper tariffs, so that the high costs for long-term therapies for chronic diseases would only be borne by the insured persons in the standard tariffs, which would then become a catchment area for financial risk patients and their insurance premiums would rise enormously. The ACA wanted to put an end to this risk for good. This draft also failed in July 2017 due to a lack of approval from both wings of the Republicans. At the end of July, the attempt by the Republicans in the US Senate to implement a significantly scaled-down version of their reform ideas (“skinny repeal”) and, based on this, to negotiate a major joint reform with the House of Representatives failed due to the rejection of the Republican Senator Susan Collins , Lisa Murkowski and John McCain . On September 25, 2017, Senators Lindsey Graham and Bill Cassidy abandoned their proposal to abolish Obamacare through regionalization of health insurance through relocation to the state level; At the end of September 2017, the possibility of implementing a reform within the reconciliation process ended for this year.

    There are approaches for a non-partisan initiative to work out an improvement in Obamacare instead of abolishing it. The president of the non-profit Kaiser Family Foundation called for this at the end of July 2017 . Some senators, led by Republican Lamar Alexander and Democrat Patty Murray, worked on such a solution in the summer of 2017; the discussions were suspended in mid-September 2017.

    The Republican majority refrained from attempting to enforce a June 2017 ruling by the Federal Court of Washington, DC , that subsidies for the socially disadvantaged did not have a sufficient legal basis. Here, too, the Republicans left the existing health system unchanged.

    On October 12, 2017, Trump signed a decree that allows insurance companies to sell cheaper policies with up to annual terms for people without high health risks, which collapses the Obamacare markets, which were previously subject to high minimum standards for a service core, and Obamacare so could bring about an administrative fall. In November 2017, the Republican majority in Congress coupled the lifting of the individual mandate , i.e. the compulsory insurance, with the budget law for 2018. As of January 1, 2019, insurance will no longer be compulsory. At the beginning of 2018, the next step was proposed to lift the obligation of all employers with more than 30 employees to offer insurance.

    Individual regulations

    Changes made by the Patient Protection and Affordable Care Act :

    Last-minute changes

    Changes that came into effect within six months of adoption:

    • Health insurance companies are prohibited from rejecting patients because of preexisting conditions .
    • Health insurance companies are prohibited from charging higher insurance premiums for children with previous illnesses.
    • Children may remain insured in their parents' family insurance until they are 26 years old.
    • In all new insurance policies, health insurers must undertake to cover the costs of preventive examinations without being able to demand additional payments from the insured.
    • All insurance companies must publish their balance sheet on the Internet and, in particular, break down the administrative costs in detail.
    • Small businesses can claim increased tax deductions when they offer health insurance to their employees .
    President Obama and other members of the government are watching the House of Representatives vote on health care reform in the White House's Roosevelt Room.

    Compulsory insurance and related reform elements

    Changes that have been in effect since April 2014:

    • Health insurance must include a minimum standard of defined benefits (bronze).
    • Health insurance companies are also prohibited from charging higher insurance premiums for adults with previous illnesses.
    • The health insurance contributions of old people cannot be more than three times as high as the health insurance contributions of young people with the same insurance company.
    • Residents with an income of up to 133% of the state-defined poverty line (2013: USD 11,490 annual income for single persons) are insured through the (welfare state) Medicaid .
    • For residents with an income of up to 400% of the state-set poverty line, health insurance contributions can be subsidized by the state, if the respective state decides on this extension.
    • Families can deduct health insurance costs more from tax than before.
    • Residents who do not have health insurance must pay fines (up to 2% of income) unless they are very poor or have religious reasons not to get health insurance.
    • Companies with more than 49 full-time employees have to pay a fine per employee if they fail to provide their employees with (adequate) health insurance coverage.
    • States are allowed to establish state-run health insurance exchanges so that small businesses ( too small for self-funded health care ) and residents without employer -sponsored health insurance can jointly take out group insurance with private health insurance providers .
    • Residents who must spend more than 9.5% of their income on health insurance contributions are allowed to take out the health insurance policy with a government agency. This authority is to set up at least two group insurances in cooperation with private health insurances, of which at least one works for the public benefit.

    Long-term reforms

    Changes that should take effect by 2018:

    • Health insurers are also obliged to cover the costs of preventive medical examinations for policyholders with long-term insurance policies without being able to demand additional payments from the insured.

    Changes made by the Health Care and Education Affordability Reconciliation Act of 2010 :

    • The state subsidy for health insurance costs for residents with an income of up to 400%, measured against the state-defined poverty line, is being expanded in relation to the Patient Protection and Affordable Care Act.
    • Medicare patients will be reimbursed up to $ 250 for prescription drugs. (This is to close the so-called "donut hole" in Medicare insurance benefits).
    • Penalty payments from residents who have not taken out health insurance are increased by an additional 0.5% of income over the Patient Protection and Affordable Care Act.
    • Payments for treatments for Medicaid patients were previously 20% lower than payments for treatments for patients without Medicaid. As a result, many doctors refused to treat Medicaid patients. The payments for Medicaid patients are therefore to be increased.
    • Companies from the 31st full-time uninsured employee must pay a fine of $ 2,000 per employee if they fail to provide their employees with (adequate) health insurance. The regulation of the Patient Protection and Affordable Care Act has been tightened.

    According to estimates by the Congressional Budget Office , this has the following effects:

    The number of uninsured people should decrease by a total of 32 million. An expansion of Medicaid is expected to reduce the number of uninsured by 17 million. Another 17 million uninsured and around 9 million already insured are to get (better) private health insurance through state health insurance exchanges, with the state paying part of the insurance premiums in most cases.

    The cost of the reform is expected to be $ 940 billion over the next 10 years. These expenditures are to be counter-financed by tax increases of $ 400 billion (mainly through a higher wage tax for high-income workers and higher income tax for residents with high capital income and the Cadillac tax on particularly expensive health insurance policies). Another major item is to reduce Medicare spending by $ 483 billion through efficiency gains. Overall, the reform is expected to reduce the budget deficit by $ 130 billion over the next 10 years.

    Indirect effects

    The compulsory insurance and the first health insurance for previously uninsured persons, especially for single younger men without children, should bring considerable advantages for the treatment of addictions and mental illnesses . Since both are considered to be the determining factors in terms of imprisonment in the sprawling prison system in the United States, there is debate over whether the insurance reform will bring about a massive decline in the US prison population in the medium and long term. The coverage of contraception by health insurance makes contraceptives much more accessible and allows contraceptive choice regardless of cost. In the first year of the law, policyholders saved approximately $ 1.4 billion. The expected consequences are a lower number of unwanted pregnancies, a higher income over the entire lifetime and fewer abortions.

    Preliminary results

    The enrollment of new insured persons should begin on October 1, 2013. However, the healthcare.gov website had massive errors and could not cope with the onslaught of citizens. Todd Park , Chief Technology Officer at the White House, put together a team of experts from October 17, who volunteered to get the site up and running within 14 days and fix all major problems within six weeks. For the most part, he used technicians who had already programmed for Obama in the 2012 presidential election campaign.

    Between October 1, 2013 and March 31, 2014, over seven million Americans signed up for health insurance. Despite the problems with implementation, the figure thus reached the previous estimate. However, surveys show that the population group that should benefit most from the reforms has so far hardly participated. The socially weakest with the lowest formal education were not reached by information and are also not interested. The media are accused of only reporting the health care reform as a political conflict and of providing far too little information about its content.

    As of April 1, 2014, the proportion of Americans without health insurance had fallen to 15.6%, almost to the values ​​before the financial crisis from 2007 onwards . By extending the enrollment phase to April 15, there was a further increase in the values; more than 8 million had been newly insured by this date. The primary reason is the expansion of Medicaid in the states that took advantage of the expansion opportunities. In addition, the recovery in the US labor market is affecting the health insurance policies offered by employers. In addition, previously uninsured employees, under the pressure of compulsory insurance, have taken out the previously offered insurance through their employer.

    Original fears that employers would abandon the brokerage of health insurance on a large scale have not been fulfilled after further observation. In the past, almost all large and many small employers supported their employees through group insurance policies, for which the company made substantial additional payments. This was an essential part of the overall package that made up employee pay. However, employers offered insurances with a very different range of services. The PPACA now requires all companies with more than 50 employees to offer insurance with a standardized range of services (bronze, silver, gold). Or they can pay a tax of just under $ 2,000 per employee annually. These taxes are earmarked to subsidize individual health insurances. Since the employer contributions for an insurance are usually well above the tax, companies could get out of health insurance. On the other hand, insurance regardless of the employer has the advantage that the employee does not have to change insurance in the event of unemployment or a change of employer. Since parts of this regulation will only come into force in 2018, further effects may arise.

    The analysis of those newly insured in 2014 showed that the desired younger target group is being reached. The long-term orientation of the program is thus on schedule. As was to be expected, however, among the younger ones, it has been predominantly those who have taken out insurance whose health is below the average of their peers and who have not been offered any insurance or no insurance that was affordable for them due to the consideration of previous illnesses. Based on the data, Paul Krugman in the New York Times concluded that the rollout was a success and accused the media and the media interviewed for systematically badmouthing the program.

    Preliminary evaluations of the first full year of the PPACA showed that in 2014, for the first time since records began, the absolute number of uninsured persons fell. At the same time and significantly more, the proportion of those who reported financial problems in everyday life due to treatment costs or who had renounced or postponed medically necessary treatments due to the costs fell. In addition, a comparison between states with the extension of Medicaid and those without it shows that people who are covered by Medicaid are far less likely to miss vital payments, such as rent, due to medical expenses and are therefore significantly less likely to become homeless.

    A significant part of the general population continues to be uninsured. In the states that took part in the expansion of Medicaid, the figure was 10.1%, in the states that refused to expand, the rate fell only slightly to 18.3%. For the second enrollment period, the government was advised to address specifically those sections of the population that had not yet been reached. This second enrollment ran from November 2014 to April 2015 and only resulted in around 68,000 new enrollments, although the uninsured has been paying increasing penalties since 2015. On the other hand, between January 2014 and April 2015, around 12 million additional US citizens were enrolled with Medicaid, so that the number of uninsured people has fallen significantly.

    The rise in costs for the entire health system could be slowed down considerably by new regulations within the framework of the ACA. Fears about the development of costs were reasons for the reform from the start.

    In 2016, insurers Anthem and CIGNA predicted losses for those insured under the Affordable Care Act. The insurance company Aetna announced that it would withdraw due to losses from the marketplaces for corresponding insurance policies in 11 of 15 states in which it was previously active. The CEO justified the move by saying that there would not be enough healthy insured persons who could finance the treatment of those with serious illnesses. Observers, however, suspected the failed attempt to merge a company with Humana Inc. as the reason for the withdrawal.

    The first two years since direct enrollment saw a decrease in the number of uninsured persons from 44 million (2013) to 28 million (2016). These are people with precarious jobs in (Republican-ruled) states that have not expanded Medicaid, or undocumented immigrants who do not have access to insurance systems.

    The law reduced the number of Americans between the ages of 18 and 64 who were uninsured from 22.3 percent in 2010 to 12.4 percent in 2016. Approximately 21 million additional Americans have health coverage ten years after the law went into effect . Ten years after the law came into effect, studies have shown that the Affordable Care Act had a positive effect on health and also caused a reduction in the death rate.

    Web links

    Commons : Patient Protection and Affordable Care Act  - Collection of Pictures, Videos, and Audio Files

    Individual evidence

    1. ↑ Supreme Court of the United States: National Federation of Independent Business v. Sebelius (PDF; 797 kB), June 28, 2012
    2. ↑ a b Obamacare: Trump softens US health care reform . In: The time . January 21, 2017, ISSN  0044-2070 ( zeit.de [accessed January 21, 2017]).
    3. ↑ a b Spiegel online: Trump's failed health reform , July 18, 2017
    4. ^ Essential Health Benefits Under The Affordable Care Act , Forbes Magazine. October 11, 2013. Archived from the original on July 28, 2017. Retrieved July 28, 2017. 
    5. ↑ University of California Los Angeles, Law School Library Overview of Patient Protection and Affordable Care Act with explanations and links
    6. ^ A b David Frum : How Republicans Can Fix American Health Care . In: The Atlantic, June 30, 2017
    7. ↑ See also: BarackObama.com Plan for a Healthy America ( Memento of February 10, 2016 in the Internet Archive ) (English, accessed November 17, 2009)
    8. ↑ a b Konrad Adenauer Foundation : Clinton, Obama, McCain: Who has the best health care reform? (German, accessed April 14, 2009; PDF; 131 kB)
    9. ^ A b The Health Care Blog: Robert Laszewski: A Detailed Analysis of Barack Obama's Health Care Reform (accessed November 17, 2009)
    10. ↑ see also: The Library of Congress: Information on the United States National Health Care Act (accessed September 13, 2009)
    11. ↑ Senator Ron Wyden: Presentation of the Healthy Americans Act ( Memento of May 5, 2010 in the Internet Archive ) (English, accessed on September 13, 2009)
    12. ↑ see also: The Library of Congress: Information on America's Affordable Health Choices Act of 2009 (accessed on September 13, 2009)
    13. ↑ Obama's Change in Danger: An Overview of the Reactions to the Reform Plans (German, accessed on August 21, 2009)
    14. ↑ Wikisource: Excerpts from the proposed law (accessed on September 13, 2009)
    15. ↑ see also: The Library of Congress: Life Sustaining Treatment Preferences Act of 2009 (accessed September 18, 2009)
    16. ↑ Investor's Business Daily: How House Bill Runs Over Grandma ( Memento of September 12, 2009 in the Internet Archive ) (English, accessed on September 13, 2009)
    17. ↑ CBS News: Palin Weighs In on Health Care Reform (accessed September 13, 2009)
    18. ↑ Anchorage Daily News: Murkowski: Don't tell lies about the health-care reform bill ( Memento of September 17, 2009 in the Internet Archive ) (English, accessed on September 13, 2009)
    19. ↑ USA-Today: End-of-life counseling had bipartisan support (accessed September 18, 2009)
    20. ↑ Daily Mail : Stephen Hawking tells US to stop attacking health service (accessed September 13, 2009)
    21. ^ Committee of Interns and Residents: What Is the Public Health Insurance Option? ( Memento of July 25, 2011 in the Internet Archive ) (accessed on October 19, 2012)
    22. ↑ Die Zeit : The Fear of Solidarity (German, accessed on November 10, 2009)
    23. ↑ FAZ : Obama advertises health reform in Congress (German, accessed on November 6, 2009)
    24. ↑ see also: WhiteHouse.gov: Speech of the President to Congress on September 9, 2009 (accessed September 13, 2009)
    25. ↑ Spiegel-online : Democrats win in battle vote over historical health reform (German, accessed on November 8, 2009)
    26. ↑ Spiegel-online : Preliminary decision in the Senate, Obama celebrates stage victory for health reform (German, accessed November 7, 2009)
    27. ^ Kaiser Family Foundation : Press review by Kaiser Health News for the vote in the Senate (English, accessed on November 22, 2009)
    28. ↑ Spiegel-Online : Obama and the healthcare reform (German, accessed December 25, 2009)
    29. ↑ Chicago Tribune : Senate vs. House Health Bill (accessed December 21, 2009)
    30. ^ Result of the vote , accessed on March 22, 2010
    31. ↑ United States Government Printing Office : Reconciliation Act of 2010 (accessed October 19, 2012)
    32. ^ Result of the vote in the House of Representatives , accessed on March 22, 2010
    33. ↑ Focus : Obama's health reform now also through the House of Representatives (German, accessed on March 30, 2010)
    34. ↑ Full text of the judgment (PDF; 0.8 MB) on the Supreme Court website, accessed on June 28, 2012
    35. ^ Spiegel.de / Marc Pitzke , judges save Obama's prestige project
    36. ↑ sueddeutsche.de: Supreme Court approves health reform
    37. ↑ [1] For general information on the issue, see also www.npr.org
    38. ↑ Supreme Court: 13–354 Burwell v. Hobby Lobby Stores, Inc. , June 30, 2014
    39. ↑ Supreme Court: King v. Burwell , June 25, 2015
    40. ^ The New York Times : Judge Backs House Challenge to a Key Part of Health Law , May 12, 2016
    41. ^ A b New York Times: Obama Unwittingly Handed Trump a Weapon to Cripple the Health Law , June 3, 2017
    42. ^ New York Times: Trump Administration to Pay Health Law Subsidies Disputed by House , April 10, 2017
    43. ↑ a b Abbe Gluck: How the GOP Sabotaged Obamacare . New York Times, May 25, 2017
    44. ↑ The Hill: Obama vetoes health bill repeal , January 8, 2016
    45. ↑ Los Angeles Times: Romney vows to repeal and replace 'Obamacare' on law's anniversary , March 23, 2012
    46. ^ New York Times: State-Level Brawls Over Medicaid Reflect Divide in GOP , December 27, 2015
    47. ^ NPR: Republicans Take The First Step To Repeal Obamacare , Jan. 3, 2017
    48. ↑ LA Times.com January 3, 2017: Republicans finally have the power to repeal Obamacare, but they're still not sure how
    49. ↑ FAZ.net May 5, 2017 / Winand von Petersdorff: The fight for Obamacare is far from over
    50. ↑ spiegel.de March 7, 2017: Republicans present Obamacare replacement
    51. ↑ spiegel.de March 14, 2017: 14 million US citizens are threatened with loss of health insurance
    52. ↑ Abolition of Obamacare in USA - forecast: 24 million fewer insured persons, n-tv.de. March 14, 2017. Retrieved March 26, 2017. 
    53. ↑ Trump calls journalists: "I am not disappointed" , n-tv.de. March 25, 2017. Retrieved March 26, 2017. 
    54. ↑ FAZ.net May 4, 2017
    55. ^ Washington Post: While House passes GOP health-care bill, Senate prepares to do its own thing , May 4, 2017
    56. ↑ spiegel.de May 5, 2017 / Veit Medick : Trump's expensive victory
    57. ^ American Healthcare Act Cost Estimate (May 2017) . Congressional Budget Office. May 24, 2017. Retrieved May 24, 2017.
    58. ^ The Atlantic : How the Senate's Health-Care Bill Would Cause Financial Ruin for People With Preexisting Conditions , June 23, 2017
    59. ^ Robert Pear, Thomas Kaplan: Senate Rejects Slimmed-Down Obamacare Repeal as McCain Votes No. In: The New York Times , July 27, 2017 (English).
    60. ↑ Jennifer Haberkorn, Burgess Everett, Seung Min Kim: Inside the life and death of Graham-Cassidy. In: Politico , September 27, 2017 (English).
    61. ^ Drew Altman, Larry Levitt: It's not Obamacare anymore. It's our national health-care system. Washington Post, July 27, 2017
    62. ↑ Tami Luhby: Republican senators ditch bipartisan healthcare talks. In: CNN.com , September 20, 2017 (English).
    63. ↑ Trump takes action against Obamacare by decree. In: Zeit Online , October 12, 2017 (English); Timothy Jost: Trump Executive Order Expands Opportunities For Healthier People To Exit ACA. In: Health Affairs , October 12, 2017 (English).
    64. ^ New York Times: Senate Plans to End Obamacare Mandate in Revised Tax Proposal , November 14, 2017
    65. ^ New York Times: Individual Mandate Now Gone, GOP Targets the One for Employers , January 14, 2018
    66. ↑ The Kentucky Post: Key Points Of The Health Care Reform Bill (accessed March 22, 2010)
    67. ^ The New York Times : Comparing the House and the Senate Health Care Proposals (accessed March 22, 2010)
    68. ^ The Committee for a Responsible Federal Budget: Updated Health Care Charts (accessed March 22, 2010)
    69. ^ The Huffington Post: Health Reform Bill Summary (accessed March 23, 2010)
    70. ^ Kaiser Family Foundation : Kaiser Health News: Nine Major Changes in New Health Reform Bill (accessed March 22, 2010)
    71. ^ The New York Times : Proposed Changes in the Final Health Care Bill (accessed July 16, 2010)
    72. ↑ Kaiser Family Foundation : It's Over! Health Care is Passed. Will it Really Work? (English, accessed March 22, 2010)
    73. ↑ newsweek: How Obamacare May Lower the Prison Population More Than Any Reform in a Generation , March 3, 2014
    74. ^ Nora V. Becker, Daniel Polsky: Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing . In: Health Affairs, Vol. 34 No. 7 (July 2015), pp. 1204–1211 doi: 10.1377 / hlthaff.2015.0127
    75. ↑ Time: Obama's Trauma Team , March 10, 2014
    76. ^ Spiegel online: US health insurance: Seven million Americans vote for "Obamacare," April 1, 2014
    77. ↑ Olga Khazan: Uninsured People Don't Like or Understand Obamacare . In: The Atlantic, March 24, 2014
    78. ^ Gallup: In US, Uninsured Rate Lowest Since 2008 , April 7, 2014
    79. ↑ a b Urban Institute: QuickTake: Number of Uninsured Adults Continues to Fall under the ACA: Down by 8.0 Million in June 2014 , July 10, 2014
    80. ^ RAND Corporation: Changes in Health Insurance Enrollment Since 2013 , April 2014
    81. ^ The Wire: The Number of Uninsured Is Dropping, but Not Thanks to Obamacare Exchanges , April 9, 2014
    82. ^ Standard & Poors: The Affordable Care Act Could Shift Health Care Benefit Responsibility Away From Employers, Potentially Saving S&P 500 Companies $ 700 Billion , May 1, 2014
    83. ↑ a b c Kaiser Family Foundation: 2015 Employer Health Benefits Survey , September 2015
    84. ^ A b Gallup: After Exchanges Close, 5% of Americans Are Newly Insured , June 23, 2014
    85. ^ New York Times: The Incompetence Dogma , June 27, 2014
    86. ^ Commonwealth Fund: The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect , January 2015
    87. ^ Kriston Capps: For the Poor, Obamacare Can Reduce Late Rent Payments . In: Citylab, December 4, 2018
    88. ^ New York Times: Health Insurance Deadline Passes for Most, but There Are Exceptions , May 1, 2015
    89. ↑ Politico of May 13, 2015. Quoted from: Kaiser Family Foundation: Expansion Debates Reheat As Medicaid Enrollment Exceeds Expectations , May 14, 2015
    90. ↑ Carolyn Y. Johnson and Juliet Eilperin, “Aetna decision exposes weaknesses in Obama's health-care law,” Washington Post, August 16, 2016
    91. ^ Kaiser Family Foundation: Key Facts about the Uninsured Population , November 29, 2017
    92. ^ Affordable Care Act at 10: Amid coronavirus, never more popular, threatened or necessary , USA Today. March 23, 2020. Archived from the original on March 31, 2020. Retrieved on March 31, 2020. 
    93. ↑ a b Obamacare Turns 10. Here's a Look at What Works and Doesn't. , The New York Times. March 23, 2020. Archived from the original on March 30, 2020. Retrieved on March 31, 2020.