The Affordable Care Act

AKA

“Obamacare”
A Research Summary Report By Tania Ballard
MG 460 Directed Study/Research in Management

Instructor Dr. J. Wayne McCain

ATHENS STATE UNIVERSITY

College of Business
April 20, 2011
NOTICE: This paper does not necessarily represent the opinion of the Administration, Faculty, or Staff of Athens State University.
 Affordable Care Act Page 2 of 25

ABSTRACT

The Affordable Care Act, AKA “Obamacare”

The Affordable Care Act (ACA) passed in March 2010 in March 2010 at the insistence of
then President Barak Obama and Democrat-controlled House Speaker Nancy Pelosi has
promised Americans a reduction in healthcare costs along with increased coverage for millions
and a decreased set of limitations and restrictions. This research paper summarizes the major
provisions of the new 1900-plus page law and addresses some important issues raised by what
now appears to be a majority of Americans concerning its constitutionality, empty promises,
private citizen/employer mandates, and what may be increased taxes and elevated healthcare
costs. At best, many view the legislation as a foundered attempt at ‘insurance reform’ rather than
an earnest effort to address the real issues that are driving the spiraling cost of medical care. In
the context of business, this law is anything but ‘business-as-usual’ and may actually result in a
significant addition to U.S. deficit spending, loss of jobs, and a decrease in medical coverage for
many already covered by ‘satisfactory’ health insurance. These concerns are coupled with the
real possibility of increased insurance costs for those already enrolled in employer-provided
plans.
This paper is intended to point to issues rather than provide succinct solutions. It is also
written as the author’s interpretation of publically-known facts and opinion’s of professional
legislators on all sides. As such, it does not represent the official position of the Administration,
Faculty, or Staff of Athens State University.
 Affordable Care Act Page 3 of 25

The Affordable Care Act, AKA “Obamacare”

Do the American people want the

future of health care to be in the hands of a

few politicians; the same politicians that are

making themselves exempt from their own

policies? When it comes to our health care

system, most of us agree that America is

ready for a change. We need a system that

delivers accessible, high quality care, but we can’t achieve this goal with government policies

that attack the foundation of our current health care system which is employer-sponsored health

insurance. The Obama administration and members of congress are pushing legislation to set up

a government run health care system. This government-run system would operate in competition

with private health insurance that is commonly provided by many employers to employees and

their families. Employer sponsored health insurance is the backbone of our nation’s health care

system and if this health insurance is banished this would affect millions of Americans. It has

been stated so many times that the law will reduce the nation's deficit by more than $100 billion

by 2020 and by $1 trillion by 2030. So far there is no evidence to find this statement true. It has

been hard to find any positive information on the bill thus far (Refer to Table 4, page 19 for a

Pros and Cons list).

The health care system in the United States has been a subject of debate for many years

as well as the topic of campaign pledges by many who have run for office. Not long ago, in fact,

President Obama made a campaign promise to make better and more health care services
 Affordable Care Act Page 4 of 25

inexpensive for all. The Affordable Care Act (ACA), which was passed in March 2010, will be

phased in over the next four years (refer to Table 3 on page 15). These next few statements are

statements that the Obama administration wants the Americans to believe is going to take place

with this new health care plan. Such as, dozens of very important provisions have been applied

already, including small business tax credits, the Medicare recipient drug rebate, the

reinsurance program for retiree coverage, the pre-existing condition insurance plans, the

coverage of children up to age 26 on their parents’ plans, and many more. The current

administration wants it to seem like that whether you get insurance through work, buy it

yourself, have a small business, are on Medicare, or don't currently have insurance, the

Affordable Care Act gives you control to make your own decisions regarding your health

coverage. It is said that the Affordable Care Act makes insurance more affordable by providing

the largest middle class tax cut for health care in history - dropping premium costs for millions

of families and small business owners who are priced out of coverage today. In turn this is

supposed to help 32 million Americans afford health care

and make coverage more affordable for many more.

According to Veronique de Rugy in an article titled “Does

Obamacare Reduce Health Care Spending?” The short

answer is no. Using the Congressional Budget Office (CBO)

data, Figure 1 shows that the Patient Protection and

Affordable Care Act and the Health Care and Education

Reconciliation Act of 2010 have left the cost curve of

federal healthcare spending virtually unchanged over the

next 25 years. The CBO finds that the effect of the healthcare legislation has been to increase
 Affordable Care Act Page 5 of 25

government spending by $3.8 trillion between 2010 and 2020. From 2020 to 2035, federal

spending under the two projections are equal percentages of GDP.”

The Patient Protection and Affordable Care Act, as improved by the reconciliation bill, is

said to ensure that all Americans have access to quality, inexpensive health care and will produce

the modification within the health care system needed to contain costs. A popular opinion is that

this trillion dollar takeover of health care will just make things worse for Americans.

FIGURE 1 – CBO Data Showing Projected Effects on Healthcare Costs

The plan will add hundreds of billions of dollars to the deficit. It would also mean new

taxes and a huge backdoor premium that will make health care costs even higher, not lower.

Businesses and taxpayers will be stuck paying for a government run plan through higher taxes,

these costs are cost that no one can afford at this time when the economy is facing real

challenges.
 Affordable Care Act Page 6 of 25

With so many challenges and problems that so many families are already facing, the

healthcare bill would be another burden for a family, as well as a business. Table 1 lists changes

that will take affect with premiums under the new healthcare bill. According to Michael Tanner

in an article (Bad Medicine 2011), he states, “the biggest businesses, those with more than 100

employees, would see the biggest benefit under PPACA, but even here the benefit would be

minimal. Under the best case scenario, the premiums for a family plan would only increase to

$20,100, compared with $13,375 today, and $20,300 if the bill hadn’t passed. That represents a

savings of $200 over what would have happened if the bill had not passed, but still represents a

$6,350 increase over what the company is paying today. Small businesses would see a premium

increase between zero and just 1 percent less than would otherwise occur. Then again under the

best-case scenario, small business premiums for a family plan would only increase to $19,200,

compared to $19,300 if the bill hadn’t passed, a savings of just $100. But the millions of

Americans who purchase insurance on their own through the non-group market will actually be

worse off as a result of this law.”

TABLE 1 – PPACA Premium Costs

The new health care reform will cover fewer medical procedures and each American will

have long waiting periods before they can get the medical care they seriously need. Under this
 Affordable Care Act Page 7 of 25

plan if you need surgery or a transplant it may

take so long for the government to O.K. the

medical procedure that one might need, that

that person may die before the treatment is

approved. Other countries with this same

government run plan has put price tags on the

lives of their citizens. This health care plan

oversees your care and it makes the ill patients

wait for the critical care they need to survive.

When the reform starts to play a huge role in the medical field, it will not be a surprise

that the demand for medical services to increase with the health care reform proposal. Anyone

can buy insurance without limitations on pre-existing conditions. The people will likely utilize

more services because now they will have the insurance to go to the doctor more often. Even

though most disadvantaged people did have some access to health care even before reform, it's

different when you know you can walk in and be treated like a regular insured person. This

reform will increase the demand for medical services.

According to MSNBC (2011), “the House Republicans have voted to begin the work of

replacing President Barack Obama's landmark law that expands health insurance coverage.” The

huge wave of smaller-government response that crashed down on the Washington authorities has

been building for a long time, picking up steam with each passage of legislation that prolonged

the government’s violation into the lives of the American people. Central to all of this has been

the conflict surrounding health care reform. The bill creates within the federal government a

nationwide Health Insurance Exchange. It has been stated that the uninsured individuals would
 Affordable Care Act Page 8 of 25

be free to purchase an Exchange plan, as would those whose existing employer coverage is

considered lacking by the federal government. Once considered eligible to enroll in the

Exchange, individuals would be allowed to remain in the Exchange until becoming Medicare

eligible.

According to a letter addressed to, The Members of the U.S. House of Representatives,

written by R. Bruce Josten (2010); “The U.S. Chamber of Commerce, the world’s largest

business federation representing the interests of more than three million businesses and

organizations of every size, sector and region, strongly opposes the Senate-passed version of

H.R. 3590, the Patient Protection and Affordable Care Act. The bill is fundamentally flawed as

its underlying framework is the wrong approach to health reform.” According to the U.S.

Chamber of Commerce there are several problems with H.R. 3590 and they are as follows:

ƒ “Employer Mandate: The bill creates a damaging new mandate on employers that
would force them either to offer a government-mandated level of coverage or be liable
for significant new taxes;
ƒ New Taxes: The bill imposes nearly $500 billion in new taxes, many of which would fall
squarely on small businesses. Taxes on medical devices and prescriptions would be
passed through to consumers. Taxes on insurance plans would be passed on directly to
small businesses, as large self-insured employers are exempt;
ƒ Dangerous Entitlements and Medicare Cuts: The bill cuts approximately $500 billion
from Medicare. However, despite double-counting by the Congressional Budget Office
(CBO), this money will not be used to shore up the Medicare trust fund, which is
projected to be bankrupt by 2017. Rather, it will be used to create a vast new entitlement
that will transfer government funds to families making up to $88,000 a year;
ƒ Expensive Plan Requirements: Every health plan will be required to meet certain
standards set by the federal government, except for “grandfathered plans,” which the
President’s proposal essentially eliminates. The end result of these new requirements,
 Affordable Care Act Page 9 of 25

according to CBO, is that health insurance on the individual market will be 10-13% more
expensive if H.R. 3590 is enacted, than if nothing is done;
ƒ Weak Cost Containment: The bill would do little to lower costs and for many would in
fact increase them, which is in part because numerous common-sense cost-containments
approaches are not included in the legislation.
o The bill contains only an inconsequential “sense of the Senate” nod to medical
liability reform, despite CBO’s finding that caps on punitive damages for doctors
could save $54 billion for the government and untold amounts for the private
sector.
o The bill does not allow all Americans to purchase health insurance across state
lines, which the CBO found would lower health care costs by 5%.
o The bill does not allow new small business pooling arrangements, which the CBO
found would not only increase coverage, but would also save money for the
federal government and the states by getting people off the Medicaid program and
into employer-sponsored plans.
o The bill would do nothing to curtail state benefit mandates that drive up the costs
of health insurance for small business.
o The bill would not make changes to successful high-deductible health plan
models to help them work better with innovative care concepts like patient-
centered medical homes.
o Lastly, the bill would not do enough to move away from fee-for-service and
toward outcome- and quality-based reimbursement for medical providers; and
ƒ Unworkable Small Business Tax Credits: Because of the extremely low wage
restrictions for small businesses to be eligible for credits, hardly any small businesses
would be eligible. Those businesses that are eligible would be required to offer highly
comprehensive plans and pay the vast majority of the employees’ premiums – and after
two or three years, the credit would vanish entirely, leading to an immediate spike in a
small businesses’ cost. These factors make it highly unlikely that most small businesses
would, or would be able to, take advantage of this credit.”
 Affordable Care Act Page 10 of 25

The Chamber of Commerce stated that there are several problems with the bill, H.R. 3590

and those problems were stated very bluntly in the letter addressed to the U.S. House of

Representatives in March 2010. The bill was actually passed in March 2010, so this statement

tells me that even before the bill was passed, the problems were addressed to the senate but the

bill was still passed. As more than half of all high-income filers are small businesses, this bill

would cripple small businesses and destroy jobs during a deep recession. Many may be

concerned that this provision would lead to many companies dropping their current coverage as a

result. According to Curtis Dubay, in an article called, Obamacare and New Taxes: Destroying

Jobs and the Economy (2011), it discussed how, “ the Patient Protection and Affordable Care

Act (PPACA) imposes numerous tax hikes that transfer more than $500 billion over 10 years—

and more in the future—from hardworking American families and businesses to Congress for

spending on new entitlements and subsidies.” This bill contains 18 separate tax increases (listed

in Table 2), which in the long run will cost taxpayers $503 billion between 2010 and.2019.

According to Bussinessweek.com, “two weeks after Republicans took control of the House in

January 2011; they kept a key campaign promise and voted to repeal President Barack Obama's

health-care law. The Democratic Senate later rejected the repeal, but House Republicans say they

still plan to "replace Obamacare with something that's a lot better. Their focus is to lower the

cost of care” (Lerer et al., 2011). When the Republicans went in keeping a promise to the people

and voted to repeal this bill, I feel as though they should have gone in with a better plan rather

than just going in with nothing to offer as a trade. In a recent article by Jason Millman (2011), it

was stated that the “republicans are also challenging how much authority Sebelius has to alter a

new long-term care insurance program, which she acknowledges is “totally unsustainable” in its
 Affordable Care Act Page 11 of 25

current form. But Republicans are pointing to a new Congressional Research Service (CRS) that

questions just how much power Sebelius has to make changes to the voluntary program.

TABLE 2 – Obama Care Taxes (ref: heritage.org)

 Affordable Care Act Page 12 of 25

The CRS report said a court may find the sweeping healthcare reform law does not provide the

HHS secretary with the authority to raise minimum earnings requirements in order to be eligible

for the program.” While the Secretary will be required to "negotiate" reimbursement rates with

doctors and hospitals, nothing in the law prohibits the Secretary from using such cooperation to

enforce Medicare reimbursement levels on providers as part of a government-imposed

"negotiation." The law requires the Secretary to "establish conditions of participation for health

care providers" under the government-run plan-however it includes no guidance or conditions

under which the Secretary must establish those conditions. Many may be concerned that the bill

would allow the Secretary to prohibit doctors from participating in other health plans as a

condition of participation in the government-run plan.

Both Virginia and Florida have challenged the act’s requirement that individuals must

carry health insurance as unconstitutional. Twenty-four other states have signed onto the lawsuit

as plaintiffs. According to Becker’s Hospital Review.com (2011), here are “13 legal issues

affecting hospitals and health systems in 2011”:

ƒ Lawsuits against the mandate to buy health insurance,

ƒ HIPAA and data breaches,

ƒ Antitrust issues and ACOs,

ƒ False claims and whistleblower suits,

ƒ Anti-Kickback and physician-hospital issues,

ƒ Impact of Stark Law on physician-hospital relationships,

ƒ Recovery audit contractors,

ƒ Compliance requirements for tax-exempt hospitals,

 Affordable Care Act Page 13 of 25

ƒ Co-management arrangements,

ƒ Changes in reimbursement,

ƒ Labour and employment issues,

ƒ Mergers and antitrust law, and

ƒ Medical malpractice and tort reform.

The question of whether the Health Care Reform is constitutional is a hot topic in today’s

society. The answer to this question is different based on the individual who answers it and

which way their political views lean. Republicans would state no, while Democrats would most

likely argue yes. At the present time, the majority of individuals are stating that it is not

constitutional. The president and the Democratic congressional leadership are fighting frantically

to pass, with no Republican votes, the ever-less-popular health bill. On the short end of the vote,

Democrats challenged Republican claims and highlighted politically popular elements of the bill

that would be wiped out if repeal took effect. With all the arguing going on between Democrats

and the Republicans, the Republicans have been accused of hypocrisy by voting to repeal a vast

expansion of health care at the same time they had signed up for coverage for their families

through a government-organized program available [only] to lawmakers.

While the Republican-led House can pass legislation to repeal, the Senate, where the

Democrats presently hold a 53 to 47 advantage, is less likely to collect the votes to pass similar

legislation. Even if the a few embattled Senate Democrats were pulled over to the Republican

side, there would not be enough of the 66 votes required to overcome a Presidential veto. The

more realistic track will be the defunding effort that will take place as components of the Act are

brought up for implementation funding. The House can simply hold up funding by refusing
 Affordable Care Act Page 14 of 25

appropriations or tying things up in committee hearings. While this is a slower process, it can

also cause a lot more pain by drawing out all of the Act’s defects holding them up to public

scrutiny, which never really occurred during its backdoor passage.

In the end, the

Affordable Health Care

Act may not be repealed

during this current session

of Congress, but it will be

starved, scrutinized and

assaulted in such a way

that it will remain as a

political ball and hammer

for pro-reform candidates in the next election. According to James Oliphant of the Los Angeles

Times, “the public’s attitude toward the law, however, has not shifted much at all. The

Affordable Care Act remains almost as equally loathed and celebrated as it was 12 months ago,

despite the best efforts of Democrats to praise it and Republicans to bury it. Even worse for both

sides, a majority of Americans remain confused about what the law actually accomplishes”.

Table 3 lists the major provisions/timetable of the Affordable Care Act and Table 4 summarizes

perceived pros and cons. If left standing, the law’s overall effect on business growth and

prosperity in this country is certainly controversial. But, most do agree that the result would be

monumental and historic, regardless of the net economic outcome.

 Affordable Care Act Page 15 of 25

TABLE 3
PROVISIONS OF THE AFFORDABLE CARE ACT, BY YEAR

YEA TOPIC INFORMATION IMPLEMENTATION DATE

R
2010 NEW CONSUMER PROTECTIONS Putting Information for Consumers Online. Effective July 1, 2010.

Prohibiting Denying Coverage of Children Based on Pre- Effective for health plan years beginning on or
Existing Conditions. after September 23, 2010 for new plans and
existing group plans.

Prohibiting Insurance Companies from Rescinding Coverage.
Eliminating Lifetime Limits on Insurance Coverage.
Regulating Annual Limits on Insurance Coverage.
Effective for health plan years beginning on or
after September 23, 2010.
Effective for health plan years beginning on or
after September 23, 2010.
Effective for health plan years beginning on or
after September 23, 2010.

Appealing Insurance Company Decisions. Effective for new plans beginning on or after
September 23, 2010.

Establishing Consumer Assistance Programs in the States. Grants Awarded October 2010.

IMPROVING QUALITY AND Providing Small Business Health Insurance Tax Credits. Effective now.
LOWERING COSTS

Offering Relief for 4 Million Seniors Who Hit the Medicare First checks mailed in June, 2010, and will
Prescription Drug “Donut Hole. continue monthly throughout 2010 as seniors
hit the coverage gap.

Providing Free Preventive Care. Effective for health plan years beginning on or
after September 23, 2010.
 Affordable Care Act Page 16 of 25

Preventing Disease and Illness. Funding begins in 2010.

Cracking Down on Health Care Fraud. Many provisions effective now.

INCREASING ACCESS TO Providing Access to Insurance for Uninsured Americans with National program effective July 1, 2010.
AFFORDABLE CARE Pre-Existing Conditions.

Extending Coverage for Young Adults. Effective for health plan years beginning on or
after September 23.

Expanding Coverage for Early Retirees. Applications for employers to participate in

the program available June 1, 2010.

Rebuilding the Primary Care Workforce. Effective 2010.

Holding Insurance Companies Accountable for Unreasonable Grants awarded beginning in 2010.
Rate Hikes.

Allowing States to Cover More People on Medicaid. Effective April 1, 2010.

Increasing Payments for Rural Health Care Providers. Effective 2010.

Strengthening Community Health Centers. Effective 2010.

2011 IMPROVING QUALITY AND Offering Prescription Drug Discounts. Effective January 1, 2011.
LOWERING COSTS

Providing Free Preventive Care for Seniors. Effective January 1, 2011.

Improving Health Care Quality and Efficiency. Effective no later than January 1, 2011.
 Affordable Care Act Page 17 of 25

Improving Care for Seniors After They Leave the Hospital. Effective January 1, 2011.

Introducing New Innovations to Bring Down Costs. Administrative funding becomes available
October 1, 2011.

INCREASING ACCESS TO Increasing Access to Services at Home and in the Community. Effective beginning October 1, 2011.
AFFORDABLE CARE

HOLDING INSURANCE COMPANIES Bringing Down Health Care Premiums. Effective January 1, 2011.
ACCOUNTABLE

Addressing Overpayments to Big Insurance Companies and Effective January 1, 2011.

Strengthening Medicare Advantage.

2012 IMPROVING QUALITY AND Linking Payment to Quality Outcomes. Effective for payments for discharges
LOWERING COSTS occurring on or after October 1, 2012.

Encouraging Integrated Health Systems. Effective January 1, 2012.

Reducing Paperwork and Administrative Costs. First regulation effective October 1, 2012.

Understanding and Fighting Health Disparities. Effective March 2012.

INCREASING ACCESS TO Providing New, Voluntary Options for Long-Term Care The Secretary shall designate a benefit plan no
AFFORDABLE CARE Insurance. later than October 1, 2012.

2013 IMPROVING QUALITY AND Improving Preventive Health Coverage. Effective January 1, 2013.
LOWERING COSTS

Expanding Authority to Bundle Payments. Effective no later than January 1, 2013.

 Affordable Care Act Page 18 of 25

INCREASING ACCESS TO Increasing Medicaid Payments for Primary Care Doctors. Effective January 1, 2013.
AFFORDABLE CARE
Providing Additional Funding for the Children’s Health Effective October 1, 2013.
Insurance Program.

2014 NEW CONSUMER PROTECTIONS Prohibiting Discrimination Due to Pre-Existing Conditions or Effective January 1, 2014.
Gender.

Eliminating Annual Limits on Insurance Coverage. Effective January 1, 2014.

Ensuring Coverage for Individuals Participating in Clinical Effective January 1, 2014.

Trials.
IMPROVING QUALITY AND Making Care More Affordable. Effective January 1, 2014.
LOWERING COSTS
Establishing Health Insurance Exchanges. Effective January 1, 2014.

Increasing the Small Business Tax Credit. Effective January 1, 2014.

INCREASING ACCESS TO Increasing Access to Medicaid. Effective January 1, 2014.

AFFORDABLE CARE

Promoting Individual Responsibility. Effective January 1, 2014.

Ensuring Free Choice. Effective January 1, 2014.

2015 IMPROVING QUALITY AND Paying Physicians Based on Value Not Volume. Effective January 1, 2015.
LOWERING COSTS

TABLE 4 - PROS AND CONS LIST
PRO Health Care Reform Law
1. Keeping Insurance Coverage
PRO: "No matter how we reform health care, we will keep this
promise: If you like your doctor, you will be able to keep your
doctor. Period. If you like your health care plan, you will be
able to keep your health care plan. Period. No one will take it
away. No matter what. My view is that health care reform
should be guided by a simple principle: fix what’s broken and
build on what works.”
Barack H. Obama, JD
44th President of the United States
Address to the annual meeting of the American Medical Association,
June 15, 2009
2. Quality of Care Improvements
PRO: "Patient care under Medicare will improve as pilot
programs to improve efficiencies are implemented. Doctors
and hospitals are encouraged to coordinate care through
payment incentives. For the first time, Medicare will reward
quality, not quantity; thus, bonus payments will be given to
those doctors and hospitals that provide good quality care."
Alliance for Retired Americans (ARA)
"Medicare Benefits and Changes," www.retiredamericans.org,
Apr. 2010
3. Private Health Insurance VS. Socialism
PRO: "Opponents of health insurance reform continue to
spread myths, including peddling the bogus notion that the
health reform bill is 'socialism' and a 'government takeover of
health care.' The fact is the reform legislation builds on our
existing private health insurance system...
[H]ealth insurance reform legislation expands private health
insurance in America, and is based on increasing choice and
competition... among a variety of private insurance plans."
Affordable Care Act Page 19 of 25
CON Health Care Reform Law
CON: "According to experts, more than 87 million American
could lose access to their current health care plan under the
new law. Workers at a majority of the nation’s employers –
including as many as four out of every five small businesses –
would lose their current coverage, thus providing further
evidence that ObamaCare is doing exactly the opposite of what
Democrats promised it would do."
John Boehner
Minority Leader of the United States House of Representatives (R-
OH)
"Obamacare, Three Months of Broken Promises,"
www.gopleader.gov,
June 23, 2010
CON: "...[O]ur care will suffer. If the Democrats' plans
become law, fewer than 700,000 physicians would be available
to treat a patient population growing in size, aging in years,
shunning medical education and receiving 'free' health care or
insurance coverage from the government in increasing
numbers.
The result will be longer wait times to see a doctor and a
decline in the high quality of care Americans are accustomed to
as overworked physicians try to keep up."
Investor's Business Daily
"The Doctor Shortage," www.investors.com, Mar. 4, 2010
CON: "Obama is a socialist. If you take over banks, if you take
over car companies, if you take over financial institutions, the
way that he has - now the health care system. If you're going to
use every crooked deal that you can come up with to get a bill
like that passed - most recently the health care bill - that is by
definition, if you look up the dictionary definition of socialism,
this is it.”
Sean Hannity
Host of Fox News Channel’s Hannity show
Interview with CNSnews.com, Mar. 25, 2010

Nancy Pelosi
Speaker of the US House of Representatives (D-CA)
"Health Insurance Reform Mythbuster - 'Democrats' Health Insurance
Refrom Is Socialism and a Government Takeover," www.speaker.gov,
Mar. 19, 2010
4. Constitutionality
PRO: "The Constitution gives Congress the power to tax and
spend money for the general welfare. This tax [PPACA]
promotes the general welfare because it makes health care
more widely available and affordable. Under existing law,
therefore, the tax is clearly constitutional...
Many important and popular government programs are based
[on] Congress's ability to give incentives through taxation and
redistribute tax revenues for public purposes. To strike down
the individual mandate the Supreme Court would have to
undermine many years of precedents justifying these programs
that stretch back to the New Deal (and in the case of the rules
for direct taxes, to the very founding of the country).
Opponents of the individual mandate insist that they are only
defending individual freedom, but they are actually taking a far
more radical position. They are really claiming that it is
unconstitutional to make Americans pay taxes."
Jack M. Balkin, JD, PhD
Knight Professor of Constitutional Law and the First Amendment at
Yale Law School
"Is the Health Care Law Unconstitutional?," New York Times,
Mar. 28, 2010
5. Insurance Premium Reductions
PRO: "We estimate that, on net, the combination of
provisions in the new law will... lower premiums by nearly
$2,000 per family...
Without reform, premiums are expected to increase from
$13,305 in 2010 to $21,458 in 2019. Relative to this increase,
premiums under reform increase only threequarters as much.
By 2019, family premiums are nearly $2,000 lower. Adding
reductions in out-of-pocket costs and lower taxes for Medicare
and Medicaid will result in estimated savings for the typical
family of over $2,500 that year."
Center for American Progress (CAP)
"The Impact of Health Reform on Health System Spending,"
www.americanprogress.org, May 2010
Affordable Care Act Page 20 of 25
CON: "Can Congress really require that every person
purchase health insurance from a private company or face a
penalty? The answer lies in the commerce clause of the
Constitution, which grants Congress the power 'to regulate
commerce... among the several states.'
...[T]he individual mandate extends the commerce clause's
power beyond economic activity, to economic inactivity. That
is unprecedented. While Congress has used its taxing power to
fund Social Security and Medicare, never before has it used its
commerce power to mandate that an individual person engage
in an economic transaction with a private company. Regulating
the auto industry or paying 'cash for clunkers' is one thing;
making everyone buy a Chevy is quite another. Even during
World War II, the federal government did not mandate that
individual citizens purchase war bonds."
Randy E. Barnett, JD
Carmack Waterhouse Professor of Legal Theory at the Georgetown
University Law Center
"Is Health-Care Reform Constitutional?," Washington Post,
Mar. 21, 2010
CON: "Throughout the year-long debate over health care
reform, President Obama promised that the legislation would
reduce the spiraling cost of health care... But a couple of new
government reports confirm what many of us who opposed a
federal takeover of the health care system feared all along -
higher costs...
CMS [Centers for Medicare and Medicaid Services] says that
the health care law will impose billions of dollars in annual
fees on manufacturers and importers of brand-name
prescription drugs and on health insurance plans, and new taxes
on medical device sales. CMS said it anticipates that these new
fees and taxes will be passed down to consumers in the form of
higher drug and device prices and higher insurance premiums,
raising health care costs from $2.1 billion in 2011 to $18.2
billion in 2018. Throughout the health care debate, Americans
were told the Democrats' health care reform measure would

6. Medical Bankruptcy Prevention
PRO: "The Senate plan limits how much even the wealthiest
family buying insurance in the Exchange can be expected to
pay, out-of-pocket, in a given year to a total of $11,900 for a
family, and $5,950 for an individual. Again, lower-income
households are expected to pay less…
These caps should virtually eliminate medical bankruptcy. The
total amount that a family can possibly owe is low enough that
providers will be willing to give them time to pay it off, and in
many cases, to negotiate discounts.
When providers know that there is no way that you can ever
pay a $50,000 bill, you wind up in bankruptcy court. When the
amounts are smaller, and doable over time, negotiations are
possible."
Maggie Mahar, PhD
Fellow at the Century Foundation
Response to Paul Starr's article "What Is in the Health Care Bill,"
www.talkingpointsmemo.com, Dec. 17, 2009
7. Federal Deficit Reduction
PRO: "CBO [Congressional Budget Office] and JCT [Joint
Committee on Taxation] estimate that enacting both pieces of
legislation—H.R. 3590 and the reconciliation proposal—would
produce a net reduction in federal deficits of $143 billion over
the 2010–2019 period as result of changes in direct spending
and revenues. That figure comprises $124 billion in net
reductions deriving from the health care and revenue
provisions and $19 billion in net reductions deriving from the
education provisions."
Congressional Budget Office (CBO)
Report (untitled) on the estimated budgetary effects of the March 2010
health care reform laws, www.cbo.gov, Mar. 20, 2010
Affordable Care Act Page 21 of 25
make premiums more affordable; instead, as the President's
own actuary at CMS confirms, Americans will face higher
premiums..."
Lisa Murkowski, JD
US Senator (R-AK),
New Health Care Law Will Increase Costs, Reduce Benefits,"
murkowski.senate.gov, May 18, 2010
CON: "Most people with medical bankruptcies already have
insurance, and out-of-pocket expenses will continue to be a
burden on the middle class.
• In 2009, 1.5 million Americans declared bankruptcy
• Of those, 62% were medically related
• Three-quarters of those had health insurance
• The Obama bill leaves 24 million without insurance
• The maximum yearly out-of-pocket limit for a family
will be $11,900 on top of premiums
• A family with serious medical problems that last for a
few years could easily be financially crushed by
medical cost
Real health care reform is needed. But this bill falls short of
that on many levels."
Jane Hamsher, MFA
Founder and Publisher of Firedoglake
"Fact Sheet: The Truth About the Health Care Bill,"
www.huffingtonpost.com, Mar. 19, 2010
CON: "In reality, if you strip out all the gimmicks and
budgetary games and rework the calculus, a wholly different
picture emerges: The health care reform legislation would
raise, not lower, federal deficits, by $562 billion..."
Douglas Holtz-Eakin, PhD
President of the American Action Forum and former Director of the
Congressional Budget Office
"The Real Arithmetic of Health Care Reform," New York Times,
Mar. 20, 2010

8. Tax Reductions
PRO: "The health reform legislation signed into law by
President Obama includes the largest health care tax cut in
history for middle class families, helping to make insurance
much more affordable for millions of families...
The Small Business Health Care Tax Credit can cover up to 35
percent of the premiums a small business pays to cover its
workers. In 2014, the rate will increase to 50 percent..."
Dan Pfeiffer
White House Communications Director
"Health Reform and the Recovery Act: Unprecedented Tax Cuts for
the Middle Class," www.whitehouse.gov, Apr. 13, 2010
9. Fixing the Physician Shortage
PRO: "The recently enacted PPACA (H.R. 3590) includes
numerous policies to train more primary care physicians and
increase the supply of primary care physicians. These policies
include: mandatory and increased discretionary funding for the
National Health Service Corp (NHSC), reauthorization of
Section 747 of Title VII, Training in Family Medicine, General
Internal Medicine, General Pediatrics, and Physician
Assistantship; creation of a Primary Care Training Extension
Program and increased faculty scholarship loans, redistribution
of 65% of the current unused Graduate Medical Education slots
to primary care and general surgery and allowing residents to
count their time spent in ambulatory settings to count towards
their residency requirements, such as physician offices and
community health centers; and the establishment of Teaching
Health Centers, creating primary care residency programs in
non-hospital settings."
American College of Physicians (ACP)
"Ensuring an Adequate Supply of Primary Care Internists and Other
Specialties Facing Shortages," www.acponline.org,
Apr. 7, 2010
Affordable Care Act Page 22 of 25
CON: "The Senate bill would: impose job-killing mandates
and penalties on businesses, [and] increase taxes and burdens
on small businesses... H.R. 4872 is no 'fix' for the Senate-
passed bill. It includes a long term hidden tax by deferring the
'Cadillac tax' on certain high cost health plans until 2018. The
number of Americans that will ultimately suffer from this
hidden tax will mushroom each year because the tax is indexed
to inflation...
This bill would also impose a new 3.8 percent 'Medicare tax'
on non-wage income that would target high income earners,
income from interest, dividends, capital gains, and some profits
from investments in partnerships and S-corporations. If this tax
and other tax increases included in the President's FY 2011
budget become law, certain taxpayers could expect a marginal
tax rate on capital gains and qualified dividends of 23.8
percent, and a marginal tax rate on nonqualified dividends of
43.4 percent."
US Chamber of Commerce
"H.R. 3590, the 'Patient Protection and Affordable Care Act,' and the
Related Budget Reconciliation Legislation, H.R. 4872, the 'Student
Aid and Fiscal Responsibility Act of 2009,'"
www.library.uschamber.com, Mar. 19, 2010
CON: "Questions have been raised as to whether there will be
a sufficient supply of physicians and other health professionals
to serve the nation, especially in light of concerns that the
nation was facing potentially significant shortages even before
health care reform...
[W]e project an overall shortage of 91,500 and 130,600 active
patient care physicians in 2020 and 2025 respectively, and a
primary care shortage of 45,400 and 65,800 physicians in 2020
and 2025...
These revised estimates are consistent with earlier estimates:
they indicate the health care system is likely to be facing severe
pressure as demand rises more rapidly than the supply."
Association of American Medical Colleges (AAMC)
"The Impact of Health Care Reform on the Future Supply and
Demand for Physicians Updated Projections Through 2025,"
www.aamc.org, June 2010

10. Medical Malpractice Lawsuits
PRO: "As part of a 'grand bargain' to create a bipartisan health
care bill, some have said tort reform should be included...
Look at what the actual data says: 98,000 people dead every
year from preventable medical errors, at a cost of $29 billion.
Countless more are seriously injured with astronomical costs.
The Congressional Budget Office and Government
Accountability Office have looked at tort reform multiple
times, and said it will save practically no money. They also
found no evidence of so-called 'defensive medicine,' finding
that doctors run more tests because of the fee-for-service
structure, or because of the benefits extra tests have on patient
care.
Additionally, a 2006 study from Harvard found that 97% of
cases were meritorious, totally debunking the idea that
frivolous lawsuits plague our courts. And while 46 states have
enacted some kind of tort reform, health care costs have
continued to skyrocket, while injured patients or their families
often can't seek justice...
Forty-six states have tort reform, and American families still
shoulder exorbitant health care costs. All the facts and data say
it doesn't work. There's still 98,000 people dead every year
from medical errors. But when political gamesmanship and
backroom deals take over, the facts fly out the window.
This health care bill has a long way to go. But let's be perfectly
clear: patients' rights aren't negotiable. Tort law changes won't
fix health care, but only make it more difficult for injured
patients to seek justice. Instead of bargaining away patients'
rights, Congress should [put] their safety first."
Anthony Tarricone, JD
Former President of the American Association of Justice
"Tort Reform: A Bad Bargain That Won't Fix Health Care,"
www.huffingtonpost.com, Sep. 22, 2009
Affordable Care Act Page 23 of 25
CON: "You would think that any effort to reform our health
care system would include tort reform, especially if the stated
purpose for Obama’s plan to nationalize our health care
industry is the current high costs...
Many states, including my own state of Alaska, have enacted
caps on lawsuit awards against health care providers. Texas
enacted caps and found that one county’s medical malpractice
claims dropped 41 percent, and another study found a '55
percent decline' after reform measures were passed.
Texas Gov. Rick Perry noted that, after his state enacted tort
reform measures, the number of doctors applying to practice
medicine in Texas 'skyrocketed by 57 percent' and that the tort
reforms 'brought critical specialties to underserved areas.'
These are real reforms that actually improve access to health
care.
...[R]esearch shows that around $200 billion per year could be
saved with legal reform. That’s real savings.
If you want to save health care, let’s listen to our doctors.
There should be no health care reform without legal reform.
There can be no true health care reform without legal reform."
Sarah Palin
Former Governor of Alaska
"No Health Care Reform Without Legal Reform,"
www.realclearpolitics.com, Aug. 21, 2009
 Affordable Care Act Page 24 of 25

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