Obama Care.

ACKNOWLEDGEMENT.

I HUMERA KHAN would take the opportunity to thank MUMBAI
UNIVERSITY for providing me an opportunity to perform study on a project
CARGO INSURANCE. This has been an excellent learning experience for me.
I am very grateful to my college, S.K SOMAIYA DEGREE COLLEGE, for
giving us opportunity to perform this project, as a part of the curriculum for the
bachelor of commerce (BANKING & INSURANCE).
I would like to thank our principal Dr. SANGEETA KHOLI and coordinator, of our department Prof. ARUN KUMAR DUBEY for their valuable
support.
I would personally like to thank Prof. JAIMINE VAISHNAV, our internal
guide, who guided us in the process of designing our project. They not only
helped us channel our energies and focus our attention on the various important
facts of our project design but also patiently stood by us our mistake and
discrepancies.

CHAPTER 1:

INTRODUCTION

What is The Affordable Care Act?
The Affordable Care Act (ACA), officially called The Patient Protection
and Affordable Care Act (PPACA) and sometimes called ObamaCare, is a US
law that reforms both the healthcare and health insurance industries in America.
The law increases the quality, availability, and affordability of private and
public health insurance to over 44 million uninsured Americans through its
many provisions which include new regulations, taxes, mandates, and
subsidies. The law also works to curb the growth in healthcare spending in the
US which has been rising at an unsustainable rate, among other things.
ObamaCare is the unofficial name for the Patient Protection and Affordable
Care Act (PPACA), although it’s sometimes called the Affordable Care Act
(ACA) for short.
Here is a simplified ObamaCare explanation of what every American should
know about new health care law. The Affordable Care Act (ACA) does a lot, but
luckily, most of don’t need to know the details. Let’s take a look at what we do
need to know:
• ObamaCare doesn’t create health insurance – it regulates the health insurance
industry and helps to increase the quality, affordability, and availability of
Private Insurance.
• Most people who currently have health insurance can keep it (see more on
keeping your grandfathered health plan).
• Young adults can stay on their parents’ plan until 26.
• If you don’t have coverage, you can use the new Health Insurance
Marketplace to Buy A Private Insurance Plan.
• You can Obtain Private Health Insurance during each year’s annual open
enrollment period in the Health Insurance Marketplace. Open enrollment for
2015 goes from November 15th, 2014, to February 15th, 2015.
•You won’t be able to obtain most types of private coverage that protect you
from the fee outside of open enrollment since insurers have adopted the health

insurance marketplace’s enrollment periods. Medicare and employer-based
insurance have unique enrollment periods. Medicaid and CHIP can be obtained
at anytime.
• If you don’t obtain coverage and maintain coverage throughout each year or
get an exemption, you must pay a per-month fee on your federal income tax
return for every month you are without health insurance.
• Due to a coverage gap exemption that applies to all Americans, you can go
without insurance for up to 3 months in a row without coverage.
• Beyond the coverage gap exemption, there are around 20 other exemptions
that you can qualify for.
• Insurance Purchased by the 15th of each month will start on the first of the
next month.
• In 2014, the fee is $95 per adult ($47.50 per child) or 1% of income –
whichever is higher. The family max is $285. The fee increases each year.
• The cost of your marketplace health insurance works on a sliding scale. Those
who make less, pay less.
• Americans making less than $45,960 individually or $94,200 as a family of 4
may be eligible for premium tax credits through the marketplace. Tax credits
subsidize insurance premium costs.
• If you are able to get qualified health insurance through your employer, you
won’t be able to receive marketplace tax credits unless the employer doesn’t
cover at least 60% of your premium cost, doesn’t provide quality insurance, or
provides insurance that exceeds 9.5% of your families income.
• Up to 82% of nearly 16 million uninsured U.S. young adults will qualify for
federal subsidies or Medicaid through the marketplace.
• You don’t have to use the marketplace to Buy Insurance, but you should fill
out an application to see if you qualify for assistance before shopping for
insurance outside of the marketplace.

• The ACA does away with pre-existing conditions and gender discrimination,
so these factors will no longer affect the cost of your insurance on or off the
marketplace.
• You can’t be denied health coverage based on health status.
• You can’t be dropped from coverage when you are sick.
• Health Insurers can’t place lifetime limits on your coverage. As of 2014 annual
limits are eliminated as well.
• All new plans sold on or off the marketplace must include a wide range of new
benefits. These include wellness visits and preventative tests and treatments at
no additional out-of-pocket cost.
• All full-time workers who work for companies with more than 50 employees
must be offered job-based health coverage by 2015. Employers who do not offer
coverage will pay a per-employee fee.
• Small businesses with under 50 full-time employees can use a part of the
marketplace called the SHOP (small business health options program) to
purchase group health plans for their employees.
• Small businesses with fewer than 25 full-time employees can use the
marketplace to purchase subsidized insurance for their employees.
• Medicare isn’t part of the marketplace. If you have Medicare, keep it!
• Medicaid and CHIP are expanded to provide insurance to reach up to 16
million of our nations poorest.
• When you apply for the marketplace, you’ll find out if you qualify for free or
low-cost coverage from Medicaid or the Children’s Health Insurance Program
(CHIP). You’ll also find out if you qualify for Medicare.

The History of ObamaCare

The concept behind ObamaCare was an individual mandate to obtain
insurance, coupled with subsidies for private insurance. The concept was first
put forth by The Heritage Foundation, a politically conservative think tank.
Their idea was that this was an acceptable alternative to the single-payer
initiative, “Medicare for All,” being proposed by the Clinton Administration.
Since that time health care reform was proposed and expanded upon by both
parties until it was implemented in Massachusetts by then-Governor Romney.
During the 2008 elections, health care reform became a major plank on the
platform of the Democratic party.

The Politics of ObamaCare

President Obama may have signed the Affordable Care Act into law, but
the truth is ObamaCare is the result of decades of ideas from both sides of the
isle and the health care industry. The idea of an individual mandate was first
presented by current opponents of the law the Heritage Foundation in 1989.
ObamaCare itself was in fact modeled after “Romney Care”, which is the
nickname for the health care reform law implemented in the State of
Massachusetts by then Governor Mitt Romney.

Why Is It Called ObamaCare?

The Patient Protection and Affordable Care Act was nicknamed
“ObamaCare” due to it being promoted by President Barack Obama. The term
started becoming common back in 2009 (before the final legislation was even in
place) and was widespread by the time the law was signed on March 23rd,
2010.
Although it was originally used as a pejorative term meant to pit opponents of
the President against the law, it has since been embraced by the President and
supporters of health care reform. When polled more people support the
Affordable Care Act than ObamaCare, despite them being the same thing.
Like “HillaryCare” in the 90’s or “RomneyCare” in Massachusetts,
“ObamaCare” is a simple name for a complex issue. Get more Obamacare Facts
on health care reform under the Affordable Care Act.

A Quick Overview of ObamaCare and How
it Works
The following ObamaCare Summary is a quick overview of Obama’s
health care reform. The purpose of our Obama Health Care summary is to help
you understand what ObamaCare does and how it affects you. The summary
includes a breakdown of changes to the way healthcare works in the U.S., new
ways to buy regulated health insurance, how to get cost assistance, and other
important aspects of the law that affect you.

Obama Health Care Summary
ObamaCare, officially called the Patient Protection and Affordable Care Act
(PPACA) but more often called the Affordable Care Act (ACA) for short,
reforms the health insurance industry and the American health care system as a
whole. The law contains over a thousand pages of provisions that give
Americans more rights and protections and expand access to affordable quality
health care to tens of millions of uninsured
The Patient Protection and Affordable Care Act was signed into law March
23rd, 2010 and upheld by a supreme court ruling on June 28, 2012. During the
ruling the law was changed to allow states to opt-out of expanding access to
Medicaid. Learn more about Medicaid Expansion and how this one little change
has left millions without health insurance.
The law requires all Americans have health insurance by 2014 (or pay a per
month fee for each month without minimum essential coverage). Although this
shared responsibility provision is unofficially called an individual mandate, it
was ruled to be in fact a tax and not a mandate by the June 28, 2012 Supreme
court ruling. ObamaCare doesn’t change the way insurance is obtained, you can
still buyPrivate Insurance, get employer based insurance, or get insurance
through a government program like Medicaid or Medicare. ObamaCare does
add a new way to purchase insurance however. Insurance can now be purchased
through state Health Insurance Marketplaces where shoppers can receive cost
assistance and get apples-to-apples comparisons of plans.

What Does ObamaCare Do?
Let’s take a look at some of the specific things ObamaCare does to
reform the American healthcare system and how these reforms can benefit you,
your family, and your business.
First off, ObamaCare includes new benefits, rights and protections that:
• Prohibit insurance companies from dropping your coverage if you get sick or
make an honest mistake on your application.
• Eliminate pre-existing conditions andgender discrimination so you can’t be
charged more based on your health status or gender.
• Let young adults stay on their parent’s plans until 26.
• Protect against unjustified rate hikes and give you more rights to appeal
insurance company decisions.
• Close the Medicare Part D ‘donut hole’ and keep Medicare strong for years to
come.
• And much, much, more.
Secondly, ObamaCare includes provisions to expand coverage and make it
more affordable by:
• Creating Health Insurance Marketplaces where low-to-middle income
Americans can compare plans and get lower costs on health insurance. There
are three ways to get lower costs on the marketplaces: Tax Credits for lower
premiums, Cost Sharing Reduction subsidies for lower out-of-pocket costs, and
Medicaid. Cost assistance is only offered through your state’s marketplace, or
on the official Health Insurance Marketplace HealthCare.gov.
• Expanding Medicaid to 15.9 million Americans to help “cover the gap”
between those who qualify for cost assistance through the marketplace and
those who qualified for Medicaid under previous Medicaid guidelines.
• Mandating large employers to provide coverage via the employer mandate and
providing tax credits for small businesses who offer their workers coverage via
the Small Business Health Options Program (SHOP).
• ObamaCare improves the quality of care that Americans receive by providing
better preventative and wellness services and raising the standards of basic
health care coverage.

• ObamaCare eliminates pre-existing conditions and gender discrimination
meaning no one can be charged more or be dropped from their health insurance
coverage for health or gender related reasons.
• ObamaCare gives tens of millions of low-income and middle-income
Americans access to quality health care by providing discounts through the
Health Insurance Marketplace (also known as a Health Insurance Exchange).
• Although the Affordable Care Act (ObamaCare) was signed into law in 2010,
the health care reforms it enacts roll out year by year until 2022. Many of the
biggest reforms don’t kick in until 2014.
• ObamaCare helps to ensure that Health Care Coverage is available to any legal
U.S. resident who cannot otherwise obtain “quality” healthcare through their
employer. Your access to health care is no longer in the hands of health
insurance companies.
• ObamaCare gives American employers with over 50 full-time equivalent
employees the choice between providing insurance that meets the standards of
ObamaCare or paying a penalty. This penalty helps to offset the cost of
employees who aren’t covered through their employer to purchase insurance
through the public health insurance exchanges instead of using emergency
services.
• Employers with less than the equivalent of 25 full-time equivalent employees
may qualify for tax credits, tax breaks and other assistance for insuring
employees through the Health Insurance Marketplace.
• ObamaCare increases consumer protections. These help to protect you from
being dropped while sick, denied care due to lifetime limits, denied care for preexisting conditions, and offers Americans a better legal standing against health
insurance companies.
• Unless you make over $200,000 individual / $250,000 as a family or small
business you are exempt from almost every tax ObamaCare levies aside from
the mandate to obtain insurance.
• ObamaCare requires that all Americans have health insurance either through a
private provider or through a state or federally assisted program. If you don’t
have insurance you must pay a tax equal to 1% of your income in 2014 and
2.5% in 2016.
• ObamaCare expands Medicaid to over 15 million uninsured low-income
Americans.

• The new health care law aims to reform the health care industry by cutting out
waste, reallocating where government funding goes, fixing what doesn’t work,
and most of all ensuring health care for Americans.

Is ObamaCare Working?
By the end of 2014 about 6.5 million people enrolled in a health plan on
ObamaCare’s Health Insurance Marketplace HealthCare.Gov. This included 4.5
million renewals and auto-renewals, and 2 million new enrollments.
• By the end of open enrollment 2015 an estimated 11.4 million were enrolled in
state and federal marketplaces. 10 million more were covered through Medicaid
and CHIP, with 3 million able to stay on their parents plan. Many more were
covered through employers who expanded coverage under the ACA, and on
private plans outside of the marketplace.
• A new January 2015 report by the Commonwealth Fund shows a reduction in
uninsured and more affordability and access to care under the Affordable Care
Act. In some cases numbers are the lowest since 2001, especially for lowincome and young people. This means less Americans putting off care or
struggling with medical debt.
• Due to the ACA’s cost curbing provisions health care spending in 2014 grew at
the slowest rate on record (since 1960). Meanwhile, health care price inflation
is at its lowest rate in 50 years.
• 8.2 million seniors have saved more than $11.5 billion on their prescription
drugs since 2010 – an average of $1,407 per beneficiary.
• The ACA’s provisions have helped save $19.2 billion in fraud, about a $10
million increase from the five years before that.
• Preliminary data shows that between 2010 and 2013 about 1.3 million less
events occurred, due to new ACA provisions, that could cause hospital-acquired
conditions like pressure ulcers, central line associated infections, and falls and
traumas. As a result, 50,000 fewer people lost their lives, and there were $12
billion in cost savings.
• Due to ObamaCare’s focus on quality over quantity readmissions among
Medicare beneficiaries were driven down by 150,000.

FEATURES OBAMACARE FROM 2010-2015:

2010
NEW CONSUMER PROTECTIONS
 Putting Information for Consumers Online. The law provides for
where consumers can compare health insurance coverage options and
pick the coverage that works for them. Effective July 1, 2010.

 Prohibiting Denying Coverage of Children Based on Pre-Existing
Conditions. The health care law includes new rules to prevent insurance
companies from denying coverage to children under the age of 19 due to
a pre-existing condition. Effective for health plan years beginning on or
after September 23, 2010 for new plans and existing group plans.

 Prohibiting Insurance Companies from Rescinding Coverage. In the
past, insurance companies could search for an error, or other technical
mistake, on a customer’s application and use this error to deny payment
for services when he or she got sick. The health care law makes this
illegal. After media reports cited incidents of breast cancer patients losing
coverage, insurance companies agreed to end this practice immediately.
Effective for health plan years beginning on or after September 23, 2010.

 Eliminating Lifetime Limits on Insurance Coverage. Under the law,
insurance companies will be prohibited from imposing lifetime dollar
limits on essential benefits, like hospital stays. Effective for health plan
years beginning on or after September 23, 2010.

 Regulating Annual Limits on Insurance Coverage. Under the law,
insurance companies’ use of annual dollar limits on the amount of
insurance coverage a patient may receive will be restricted for new plans
in the individual market and all group plans. In 2014, the use of annual

dollar limits on essential benefits like hospital stays will be banned for
new plans in the individual market and all group plans. Effective for
health plan years beginning on or after September 23, 2010.

 Appealing Insurance Company Decisions. The law provides consumers
with a way to appeal coverage determinations or claims to their insurance
company, and establishes an external review process. Effective for new
plans beginning on or after September 23, 2010.

 Establishing Consumer Assistance Programs in the States. Under the
law, states that apply receive federal grants to help set up or expand
independent offices to help consumers navigate the private health
insurance system. These programs help consumers file complaints and
appeals; enroll in health coverage; and get educated about their rights and
responsibilities in group health plans or individual health insurance
policies. The programs will also collect data on the types of problems
consumers have, and file reports with the U.S. Department of Health and
Human Services to identify trouble spots that need further oversight.
Grants Awarded October 2010.

IMPROVING QUALITY AND LOWERING COSTS

 Providing Small Business Health Insurance Tax Credits. Up to 4
million small businesses are eligible for tax credits to help them provide
insurance benefits to their workers. The first phase of this provision
provides a credit worth up to 35% of the employer’s contribution to the
employees’ health insurance. Small non-profit organizations may receive
up to a 25% credit. Effective now.

 Offering Relief for 4 Million Seniors Who Hit the Medicare
Prescription Drug “Donut Hole.” An estimated four million seniors will
reach the gap in Medicare prescription drug coverage known as the
“donut hole” this year. Each eligible senior will receive a one-time, tax

free $250 rebate check. First checks mailed in June, 2010, and will
continue monthly throughout 2010 as seniors hit the coverage gap. Learn
more about the "donut hole" and Medicare.

 Providing Free Preventive Care. All new plans must cover certain
preventive services such as mammograms and colonoscopies without
charging a deductible, co-pay or coinsurance. Effective for health plan
years beginning on or after September 23, 2010.

 Preventing Disease and Illness. A new $15 billion Prevention and
Public Health Fund will invest in proven prevention and public health
programs that can help keep Americans healthy – from smoking cessation
to combating obesity. Funding begins in 2010.See prevention funding and
grants in your state.

 Cracking Down on Health Care Fraud. Current efforts to fight fraud
have returned more than $2.5 billion to the Medicare Trust Fund in fiscal
year 2009 alone. The new law invests new resources and requires new
screening procedures for health care providers to boost these efforts and
reduce fraud and waste in Medicare, Medicaid, and CHIP. Many
provisions effective now.

INCREASING ACCESS TO AFFORDABLE CARE
 Providing Access to Insurance for Uninsured Americans with PreExisting Conditions. The Pre-Existing Condition Insurance Plan
provides new coverage options to individuals who have been uninsured
for at least six months because of a pre-existing condition. States have the
option of running this program in their state. If a state chooses not to do
so, a plan will be established by the Department of Health and Human
Services in that state. National program effective July 1, 2010.

 Extending Coverage for Young Adults. Under the law, young adults will
be allowed to stay on their parents’ plan until they turn 26 years old (in
the case of existing group health plans, this right does not apply if the
young adult is offered insurance at work). Check with your insurance
company or employer to see if you qualify. Effective for health plan
years beginning on or after September 23.

 Expanding Coverage for Early Retirees. Too often, Americans who
retire without employer-sponsored insurance and before they are eligible
for Medicare see their life savings disappear because of high rates in the
individual market. To preserve employer coverage for early retirees until
more affordable coverage is available through the new Exchanges by
2014, the new law creates a $5 billion program to provide needed
financial help for employment-based plans to continue to provide
valuable coverage to people who retire between the ages of 55 and 65, as
well as their spouses and dependents. Applications for employers to
participate in the program available June 1, 2010. For more information
on the Early Retiree Reinsurance Program.

 Rebuilding the Primary Care Workforce. To strengthen the availability
of primary care, there are new incentives in the law to expand the number
of primary care doctors, nurses and physician assistants. These include
funding for scholarships and loan repayments for primary care doctors
and nurses working in underserved areas. Doctors and nurses receiving
payments made under any state loan repayment or loan forgiveness
program intended to increase the availability of health care services in
underserved or health professional shortage areas will not have to pay
taxes on those payments. Effective 2010 .

 Holding Insurance Companies Accountable for Unreasonable Rate
Hikes. The law allows states that have, or plan to implement, measures
that require insurance companies to justify their premium increases will
be eligible for $250 million in new grants. Insurance companies with
excessive or unjustified premium exchanges may not be able to

participate in the new health insurance Exchanges in 2014. Grants
awarded beginning in 2010.

 Allowing States to Cover More People on Medicaid. States will be able
to receive federal matching funds for covering some additional lowincome individuals and families under Medicaid for whom federal funds
were not previously available. This will make it easier for states that
choose to do so to cover more of their residents. Effective April 1, 2010.

 Increasing Payments for Rural Health Care Providers. Today, 68% of
medically underserved communities across the nation are in rural areas.
These communities often have trouble attracting and retaining medical
professionals. The law provides increased payment to rural health care
providers to help them continue to serve their communities. Effective
2010.

 Strengthening Community Health Centers. The law includes new
funding to support the construction of and expand services at community
health centers, allowing these centers to serve some 20 million new
patients across the country. Effective 2010.

2011

IMPROVING QUALITY AND LOWERING COSTS

 Offering Prescription Drug Discounts. Seniors who reach the coverage
gap will receive a 50% discount when buying Medicare Part D covered

brand-name prescription drugs. Over the next ten years, seniors will
receive additional savings on brand-name and generic drugs until the
coverage gap is closed in 2020. Effective January 1, 2011.

 Providing Free Preventive Care for Seniors. The law provides certain
free preventive services, such as annual wellness visits and personalized
prevention plans for seniors on Medicare. Effective January 1, 2011.
.
 Improving Health Care Quality and Efficiency. The law establishes a
new Center for Medicare & Medicaid Innovation that will begin testing
new ways of delivering care to patients. These methods are expected to
improve the quality of care, and reduce the rate of growth in health care
costs for Medicare, Medicaid, and the Children’s Health Insurance
Program (CHIP). Additionally, by January 1, 2011, HHS will submit a
national strategy for quality improvement in health care, including by
these programs. Effective no later than January 1, 2011.

 Improving Care for Seniors After They Leave the Hospital. The
Community Care Transitions Program will help high risk Medicare
beneficiaries who are hospitalized avoid unnecessary readmissions by
coordinating care and connecting patients to services in their
communities. Effective January 1, 2011.

 Introducing New Innovations to Bring Down Costs. The Independent
Payment Advisory Board will begin operations to develop and submit
proposals to Congress and the President aimed at extending the life of the
Medicare Trust Fund. The Board is expected to focus on ways to target
waste in the system, and recommend ways to reduce costs, improve
health outcomes for patients, and expand access to high-quality
care. Administrative funding becomes available October 1, 2011. Learn
more about strengthening Medicare.

INCREASING ACCESS TO AFFORDABLE CARE

 Increasing Access to Services at Home and in the Community. The
Community First Choice Option allows states to offer home and
community based services to disabled individuals through Medicaid
rather than institutional care in nursing homes. Effective beginning
October 1, 2011.

HOLDING INSURANCE COMPANIES ACCOUNTABLE
 Bringing Down Health Care Premiums. To ensure premium dollars are
spent primarily on health care, the law generally requires that at least
85% of all premium dollars collected by insurance companies for large
employer plans are spent on health care services and health care quality
improvement. For plans sold to individuals and small employers, at least
80% of the premium must be spent on benefits and quality improvement.
If insurance companies do not meet these goals, because their
administrative costs or profits are too high, they must provide rebates to
consumers. Effective January 1, 2011.

 Addressing Overpayments to Big Insurance Companies and
Strengthening Medicare Advantage. Today, Medicare pays Medicare
Advantage insurance companies over $1,000 more per person on average
than is spent per person in Traditional Medicare. This results in increased
premiums for all Medicare beneficiaries, including the 77% of
beneficiaries who are not currently enrolled in a Medicare Advantage
plan. The law levels the playing field by gradually eliminating this
discrepancy. People enrolled in a Medicare Advantage plan will still
receive all guaranteed Medicare benefits, and the law provides bonus

payments to Medicare Advantage plans that provide high quality
care. Effective January 1, 2011.

2012

IMPROVING QUALITY AND LOWERING COSTS

 Linking Payment to Quality Outcomes. The law establishes a hospital
Value-Based Purchasing program (VBP) in Traditional Medicare. This
program offers financial incentives to hospitals to improve the quality of
care. Hospital performance is required to be publicly reported, beginning
with measures relating to heart attacks, heart failure, pneumonia, surgical
care, health-care associated infections, and patients’ perception of care.
Effective for payments for discharges occurring on or after October 1,
2012.

 Encouraging Integrated Health Systems. The new law provides
incentives for physicians to join together to form “Accountable Care
Organizations.” These groups allow doctors to better coordinate patient
care and improve the quality, help prevent disease and illness and reduce
unnecessary hospital admissions. If Accountable Care Organizations
provide high quality care and reduce costs to the health care system, they
can keep some of the money that they have helped save. Effective
January 1, 2012.

 Reducing Paperwork and Administrative Costs. Health care remains
one of the few industries that relies on paper records. The new law will
institute a series of changes to standardize billing and requires health
plans to begin adopting and implementing rules for the secure,
confidential, electronic exchange of health information. Using electronic
health records will reduce paperwork and administrative burdens, cut

costs, reduce medical errors and most importantly, improve the quality of
care. First regulation effective October 1, 2012.

 Understanding and Fighting Health Disparities. To help understand
and reduce persistent health disparities, the law requires any ongoing or
new federal health program to collect and report racial, ethnic and
language data. The Secretary of Health and Human Services will use this
data to help identify and reduce disparities. EffectiveMarch 2012.

INCREASING ACCESS TO AFFORDABLE CARE

 Providing New, Voluntary Options for Long-Term Care
Insurance. The law creates a voluntary long-term care insurance program
– called CLASS -- to provide cash benefits to adults who become
disabled.

2013

IMPROVING QUALITY AND LOWERING COSTS

 Improving Preventive Health Coverage. To expand the number of
Americans receiving preventive care, the law provides new funding to
state Medicaid programs that choose to cover preventive services for
patients at little or no cost. Effective January 1, 2013.

 Expanding Authority to Bundle Payments. The law establishes a
national pilot program to encourage hospitals, doctors, and other

providers to work together to improve the coordination and quality of
patient care. Under payment “bundling,” hospitals, doctors, and
providers are paid a flat rate for an episode of care rather than the current
fragmented system where each service or test or bundles of items or
services are billed separately to Medicare. For example, instead of a
surgical procedure generating multiple claims from multiple providers,
the entire team is compensated with a “bundled” payment that provides
incentives to deliver health care services more efficiently while
maintaining or improving quality of care. It aligns the incentives of those
delivering care, and savings are shared between providers and the
Medicare program. Effective no later than January 1, 2013.

INCREASING ACCESS TO AFFORDABLE CARE
 Increasing Medicaid Payments for Primary Care Doctors. As
Medicaid programs and providers prepare to cover more patients in 2014,
the Act requires states to pay primary care physicians no less than 100%
of Medicare payment rates in 2013 and 2014 for primary care services.
The increase is fully funded by the federal government. Effective January
1, 2013.

 Open Enrollment in the Health Insurance Marketplace
Begins. Individuals and small businesses can buy affordable and qualified
health benefit plans in this new transparent and competitive insurance
marketplace. Effective October 1, 2013.

2014

NEW CONSUMER PROTECTIONS

 Prohibiting Discrimination Due to Pre-Existing Conditions or
Gender. The law implements strong reforms that prohibit insurance
companies from refusing to sell coverage or renew policies because of an
individual’s pre-existing conditions. Also, in the individual and small
group market, the law eliminates the ability of insurance companies to
charge higher rates due to gender or health status. Effective January 1,
2014. Learn more about protecting Americans with pre-existing
conditions.

 Eliminating Annual Limits on Insurance Coverage. The law prohibits
new plans and existing group plans from imposing annual dollar limits on
the amount of coverage an individual may receive. Effective January 1,
2014.

 Ensuring Coverage for Individuals Participating in Clinical
Trials. Insurers will be prohibited from dropping or limiting coverage
because an individual chooses to participate in a clinical trial. Applies to
all clinical trials that treat cancer or other life-threatening
diseases. Effective January 1, 2014.

IMPROVING QUALITY AND LOWERING COSTS

 Making Care More Affordable. Tax credits to make it easier for the
middle class to afford insurance will become available for people with
income between 100% and 400% of the poverty line who are not eligible
for other affordable coverage. (In 2010, 400% of the poverty line comes
out to about $43,000 for an individual or $88,000 for a family of four.)
The tax credit is advanceable, so it can lower your premium payments
each month, rather than making you wait for tax time. It’s also
refundable, so even moderate-income families can receive the full benefit
of the credit. These individuals may also qualify for reduced cost-sharing
(copayments, co-insurance, and deductibles). Effective January 1, 2014.

 Establishingthe Health Insurance Marketplace. Starting in 2014 if
your employer doesn’t offer insurance, you will be able to buy it directly
in the Health Insurance Marketplace. Individuals and small businesses
can buy affordable and qualified health benefit plans in this new
transparent and competitive insurance marketplace. The Marketplace will
offer you a choice of health plans that meet certain benefits and cost
standards. Starting in 2014, Members of Congress will be getting their
health care insurance through the Marketplace, and you will be able buy
your insurance through Marketplace too.

 Increasing the Small Business Tax Credit. The law implements the
second phase of the small business tax credit for qualified small
businesses and small non-profit organizations. In this phase, the credit is
up to 50% of the employer’s contribution to provide health insurance for
employees. There is also up to a 35% credit for small non-profit
organizations. Effective January 1, 2014.

INCREASING ACCESS TO AFFORDABLE CARE

 Increasing Access to Medicaid. Americans who earn less than 133% of
the poverty level (approximately $14,000 for an individual and $29,000
for a family of four) will be eligible to enroll in Medicaid. States will
receive 100% federal funding for the first three years to support this
expanded coverage, phasing to 90% federal funding in subsequent years.
Effective January 1, 2014.

 Promoting Individual Responsibility. Under the law, most individuals
who can afford it will be required to obtain basic health insurance
coverage or pay a fee to help offset the costs of caring for uninsured
Americans. If affordable coverage is not available to an individual, he or
she will be eligible for an exemption. Effective January 1, 2014.

2015

IMPROVING QUALITY AND LOWERING COSTS
 Paying Physicians Based on Value Not Volume. A new provision will
tie physician payments to the quality of care they provide. Physicians will
see their payments modified so that those who provide higher value care
will receive higher payments than those who provide lower quality
care. Effective January 1, 2015.

CHAPTER 2:
PROS AND CONS OF OBAMACARE

ObamaCare Pros and Cons
List of Pros and Cons in ObamaCare: Some people oppose ObamaCare as a
whole, but considering the 1000 plus pages of complex legislation contained
within the Affordable Care Act, it’s hard to justify a total repeal of the law. Here
are some of the things ObamaCare does right, and a few that may have a
negative impact on America

Pros of ObamaCare

Most of ObamaCare’s 2000 plus pages are filled with really impressive and
long-overdue reforms to the $2.6 trillion dollar health care system. ObamaCare
gives 30 of 44 million uninsured Americans access to health insurance. Tens of
millions of Americans have already benefited from ObamaCare’s improved
health care services and the average family has already saved thousands on
health care costs last year alone.
Here are some of the Benefits of the healthcare law:

ObamaCare Pros: New Healthcare Benefits
ObamaCare gives Americans access to hundreds of new health care benefits.
There are too many to count, and would make for a pretty unbiased (looking)
list. However these benefits,(aside form ones mentioned elsewhere on this page,
include: No annual or lifetime limits, children can stay on their parents plans to
26, FDA can approve more generic drugs driving prices down and breaking
monopolies and protections against discrimination for gender, disabilities and
domestic abuse. Check out our ObamaCare Health Care Reform Timeline for a
comprehensive list of reforms.

ObamaCare Pros: Preventive and Wellness Services
Millions of Americans now have access to preventive and wellness services
with no out of pocket costs. The specific benefits can be found on our Benefits
of ObamaCare page.

ObamaCare Pros: Consumer Protections
ObamaCare regulates insurance, referred to as the “rate hike” review, enacts the
“80/20″ rule that makes health insurance providers spend at least 80% of their
income on health and marketing expenses or must be returned as rebates and
being dropped from coverage for being sick or denied from a preexisting
condition are all out the window in the next few years. ObamaCare has a long
list of protections that are protecting your new rights, including a mandate on
fast food restaurants to display calories to promote wellness.

ObamaCare Pros: Cost Assistance for the Middle Class and Small Business
Those under 400% of the federal poverty level (Roughly 88k for a family of 4)
could save up to 60% on their premiums via tax credits and subsidies on the
health insurance exchanges. Small businesses with less than 25 full time
employees have this advantage as well.

ObamaCare Pros: Medicaid Expansion
Those under 133% of the poverty level will (in states that have not opted out of
Medicaid Expansion) will be able to be covered now that ObamaCare is
expanding Medicaid to low income Americans who were left without enough
money to afford insurance and too much to qualify for Medicaid.

ObamaCare Pros: Improvements to Medicare
ObamaCare does a lot for Medicare. For the most part these things are great and
have already benefited tens of millions of seniors. ObamaCare closes the
Medicare drug ‘donut hole’, provides improved preventive and wellness
services with no out of pocket cost and reforms aspects of Medicare to improve
overall care for seniors.

ObamaCare Pros: Quality Over Quantity
Doctors and hospitals will be moved to a system where they are rewarded for
providing quality care, instead of being reward for quantity. May of the
provisions to enforce this punish high turnover rates, this however has some
unintended consequences. Some doctors and health care institutions are getting
hit hard from this, although the overall reform will create a better health care
system for all Americans.

ObamaCare Pros: Oversight Committees
159 new boards, agencies and programs are created by ObamaCare to oversee
spending and to ensure ObamaCare is working correctly. Though sometimes
listed as a con, having oversight on a reform of this size is mandatory to ensure
to program works. It’s important to note that ObamaCare doesn’t ration
healthcare, rather it regulates the health insurance industry who have been
rationing our health care for years. Your health care is still between you and
your doctor and determined by your private insurance.

Cons of ObamaCare

Even though ObamaCare does a lot right, it does have some consequences for
specific groups of Americans. ObamaCare does hurt a small percentage of small
businesses, has had a negative effect on insurance premiums and has made some
reforms that have hurt some medical industries and their workers.

Here are some of the cons of the healthcare bill:
ObamaCare Cons: Taxes on Small Business
.2% of firms in the US have over 50 full-time employees and will have to
choose to insure full-time workers or pay a fine. To avoid this some businesses
will cut employee hours or not hire. Some things worth noting are that the fine
isn’t paid for your first 30 workers. Also, many businesses are coming up with
solutions that don’t hurt the workforce such as passing the extra costs onto
consumers. Please be aware that when politicians say, “small business” they are

also referring to the top 3% of small businesses who include Hedge Funds
which use loopholes to pass as small businesses.

ObamaCare Cons: Religious Beliefs
There is some argument over ObamaCare funding women’s health services like
contraception. There are exceptions built into the law to refuse to provide these
services to women based on religious grounds, but this has non the less been
causing issues on the ground, in the political arena and in the courts.

ObamaCare Cons: Rising Premiums
ObamaCare doesn’t raise premiums itself. In fact, it reforms the insurance
industry, finding ways to drive down costs, make the quality of insurance better
and prevent insurance company abuses like . Unfortunately, many provisions of
ObamaCare that offer protections to consumers do not go into law until 2014. In
the meantime, premium rates have been rising at alarming rates. ObamaCare
doesn’t offer a protection beyond allowing states to enact the provision against
price gouging. Many States are enforcing this, while others aren’t. ObamaCare
Insurance Premium Rate Hikes

ObamaCare Cons: ObamaCare Insurance Exchanges
Another con of ObamaCare is that 21 states planning to or are opting out of the
State Run Exchanges, letting the federal government run their exchanges for
them. The claim is that this is a cost cutting measure for the State, however the
truth is much more complicated. This provision was meant to be in the bill, but
it is being abused as a way to avoid providing subsidies to low and middle
income Americans and forcing the Federal taxpayers to take care of antiObamaCare state’s constituents. This has resulted in a 3.5% fee for insurance
companies to sell insurance on the federal exchange.

ObamaCare Cons: Tax for Not Buying Insurance
Come 2014, you must purchase insurance or pay a “penalty income tax”. The
first year it is $95 or 1% of your income. In order for the program to work at its
best ideally everyone would have insurance resulting in affordable quality

insurance for all, the tax helps offset the estimated 6 million people will pay the
fine in the first year instead of purchasing insurance.

ObamaCare Cons: Big Business Taxes
Medical device taxes and “drug innovator” taxes dig into the profits of some of
the power houses in their respective industries. These taxes are a reaction to the
large profit margins these companies have and the hold they have over the
competition. They drive up the cost of health care, thus they are taxed to help
pay for health care reform. However, taxes on large businesses may have
unintended consequences in the job market and in aspects of the health care
industry. We don’t have proof of their effects yet.

ObamaCare Cons: Taxes on the 2%
The top 2% of businesses and individuals in the US will pay some extra taxes.
You could argue that are closer to the 3% will get hit the hardest because the
have the least extra cash to stay in the game with so it hurts them more.
However, the most vocal opponents and the ones who fund the anti-ObamaCare
campaigns are the big businesses who don’t like regulation, entitlement
programs or any tax or program that affects their bottom line. Aside from the
above mentioned consequences its important not to make their interests our
own.

ObamaCare Cons: ObamaCare Hurts Medicare
ObamaCare cuts $716 billion from Medicare and reinvests the money back into
the program. Since there is such a big overhaul ObamaCare set up a committee
to oversee spending and effectiveness. Due to the sheer volume of reforms some
of them, even though well intentioned, are sure to have unintended
consequences and need adjusting. Although ObamaCare has already helped tens
of millions of seniors save money on drugs and get access to better health care,
there are some caveats.

ObamaCare Cons: ObamaCare Cost

ObamaCare is projected to cost $1.36 trillion over the next ten years, and in
order for the program to work as intended this is going to include funding from
the tax payers and from the States. However, the end result of ObamaCare’s
spending is a $200 billion dollar reduction of the deficit over the next decade,
states also receive between 90 – 100% of funding for most ObamaCare related
programs they set up. A few states, including Nevada and Michigan, have done
studies that show how the States can save billions with ObamaCare. Health
Insurance companies stand to make billions, despite a loss on profit per plan,
since they will be insuring millions of new Americans.

How to Move Forward with The Pros and Cons of ObamaCare
Fixing the parts of ObamaCare that don’t work isn’t as simple as just
“repealing” ObamaCare (an action that would cost tax payers billions). Dealing
with the pros and cons is something that is already built into the law via
oversight committees and other forward thinking provisions in the law. With so
many aspects of the Affordable Care Act still in the initial stages of growth only
time will tell it’s true impact on America.

Obamacare’s Pros, Cons for Medical Students:

The U.S. Supreme Court upheld the major portions of healthcare reform in a 5-4
decision in June 2012. Now that the U.S. elections have concluded—thus
eliminating the possibility of a Romney government, and presumably meaning
that so-called Obamacare is likelier to be here to stay—it's a good time to ask
what the legislation means for medical education and for physicians' careers.
The Affordable Care Act (ACA) has recently triggered a debate within the
medical community about both its potential impact on medical trainees and on
practicing physicians. While the president of the American Medical Student
Association has publicly supported the changes in a recent official memo, a
recent survey indicates that 40 percent of medical students may not even be
aware of the provisions of the act.

Institutional changes can often be double-edged swords, and this series of
proposed changes is no different. There are both potential benefits and
downsides to what is now widely seen as almost inevitable healthcare reform.

There are two potentially positive outcomes:

1. More medical students may be drawn to primary care specialties.
With a new emphasis on higher reimbursements for primary care
specialties, including internal medicine and family medicine, the
direction of medical education could be affected. A prominent healthcare
economic think tank posits that healthcare reform will expand
scholarships and loan repayment programs in order to draw medical
students into primary care specialties. Not so long ago, many medical
graduates were drawn into subspecialties.
This could also cause a shift in medical school elective selection down
the line, with competition for previously popular subspecialty electives
shifting to primary care ones. It is thought that these changes would not
only improve access and funding for preventative care, but that they are
also popular with many current medical students.

2. There will be more admissions slots at existing schools, and more
medical schools. For the first time since the 1990s, there are 18 medical
schools in the United States in various stages of accreditation and
development. Eleven have opened since 2007, and enrollment in both
allopathic and osteopathic medical schools has expanded in recent years.
The Association of American Medical Colleges has also said that a record
number of minority students enrolled this past year.

There are also a couple of potential downsides:

1. The larger number of M.D.'s will compete for the same number of
residencies. Though the ACA has expanded the number and diversity
of U.S. medical graduates, the number of residency spots, funded by
Medicare, has remained unchanged since a Congressional Balanced
Budget Act took effect in 1997. A larger number of U.S. medical
graduates could find themselves unmatched after graduation; in fact
The Chronicle of Higher Education reported that Texas, which ranks
42nd in the United States in the number of doctors per 100,000 people,
will graduate more medical students than it has residency slots
available by 2014.

2. Physicians may elect to work fewer hours, thus decreasing access
to care. A report issued by the Kellogg School of Management at
Northwestern University indicates that portions of the ACA,
specifically addressing cost containment and Medicare reimbursement,
may end up ultimately decreasing the access to care. Based on data
obtained after the establishment of the State Children's Health
Insurance Program (SCHIP) in 1997, the report concludes that the
program expanded access, but it eventually led to shorter patient visits
and to significant numbers of physicians electing to work fewer hours.
The report cites previous expansions of public health programs in the
United
States and Canada and concludes that physicians probably
elected to work fewer hours due to declines in reimbursements. The report
speculates that this could lead to a future drop in the quantity and quality
of medical school applicants, as the field may become less enticing.
Further research would be needed to determine this definitively, the report
adds.

15 REASONS WHY OBAMACARE DECISION IS A
DISASTER FOR AMERICA
#1 According to the U.S. Supreme Court, the federal government has the power
to force you to buy private goods and services. Now that this door has been
opened, what else will we be forced to buy in the future?

#2 Obamacare is another step away from individual liberty and another step
toward a “nanny state” where the government dominates our lives from the
cradle to the grave.

#3 The IRS is now going to be given the task of hunting down and penalizing
millions of Americans that do not have any health insurance. In fact, the Obama
administration has given the IRS 500 million extra dollars “outside the normal
appropriations process” to help them enforce the provisions of Obamacare that
they are in charge of overseeing.

#4 Obamacare imposes more than 20 new taxes on the American people. You
can find a comprehensive list of Obamacare taxes right here. If you love paying
higher taxes, then you are going to absolutely love Obamacare once it is fully
implemented.

#5 In an attempt to “control costs” and “promote efficiency”, Obamacare limits
the treatment options that doctors and patients can consider. This is likely to
result in a decrease in life expectancy in the United States.

#6 Obamacare is going to impose nightmarish paperwork burdens on doctors,
hospitals and the rest of the healthcare system. This is going to significantly
increase our healthcare costs as a nation.

#7 Obamacare is going to send health insurance premiums soaring. This is
especially true for younger Americans.

#8 Many small businesses are going to be absolutely crushed by the provisions
in Obamacare that require them to provide expensive health insurance coverage
for their employees. This is going to make them even less competitive with
companies in other countries where businesses are not required to provide
healthcare for their workers. This is also going to make it even less attractive
for businesses to hire new employees.

#9 Obamacare is going to make the emerging doctor shortage in America a lot
worse. Surveys have found that we could potentially see hundreds of thousands
of doctors leave the medical profession because of Obamacare.

#10 Obamacare has already forced the cancellation of dozens of doctor-owned
hospitals.

#11 Obamacare is going to result in a much bigger federal government. In
order to fully implement all of the provisions of Obamacare, hordes of new
government bureaucrats will be required.

#12 Thanks to Obamacare, you are going to have to wait much longer to see a
doctor. Just look at what happened once Romneycare was implemented in
Massachusetts….
In fact, we have already seen the start of this process in Massachusetts, where
Mitt Romney’s health care reforms were nearly identical to President Obama’s.
Romney’s reforms increased the demand for health care but did nothing to
expand the supply of physicians. In fact, by cracking down on insurance
premiums, Massachusetts pushed insurers to reduce their payments to
providers, making it less worthwhile for doctors to expand their practices. As a
result, the average wait to get an appointment with a doctor grew from 33 days
to over 55 days.

#13 Obamacare contains all kinds of insidious little provisions that most people
don’t even know about. The following is one example from the Alliance
Defense Fund….
“Did you know that with ObamaCare you will have to pay for life-saving drugs,
but life-ending drugs are free. One hundred percent free. If this plan were really
about health care wouldn’t it be the other way around?”

#14 As if the U.S. government was not facing enough of a crisis with
entitlement spending, it is being projected that Obamacare will add 16 million
more Americans to the Medicaid rolls. You and I will be paying for all of this.

#15 The Congressional Budget Office estimates that Obamacare will add more
than a trillion dollars to government spending over the next decade.
Considering the fact that the U.S. government is already drowning in debt, how
in the world can we afford this?

CHAPTER 3
IMPACT OF OBAMACARE:

The Affordable Care Act and Older Americans

The Affordable Care Act is providing affordability, access and quality for
older Americans. The law’s new protections include strengthening Medicare,
offering a range of preventive services at no cost, and giving discounts on drugs
when in the coverage gap (also called the “donut hole”) in prescription drug
coverage. Learn how the health care law affects all people with Medicare.

 Medicare Preventive Services
 Medicare Drug Discounts
 Strengthening Medicare

Medicare Preventive Services

Because of the Affordable Care Act, if you have Original Medicare, you may
qualify for a yearly wellness visit and many preventive services for free.
If you’re new to Medicare, your “Welcome to Medicare” preventive visit is now
covered during your first 12 months of Part B coverage. This one-time visit
includes a review of your health as well as education and counseling about
preventive services and other care. If you’ve had Part B for longer than 12
months, you can get a yearly wellness visit to develop or update a personalized
prevention plan based on your current health and risk factors. Your first yearly
wellness visit must be at least 12 months after your “Welcome to Medicare”
preventive visit if you received one.
Several Medicare preventive services that are covered without cost-sharing are
listed below. For these preventive services, you’ll generally pay nothing.
However, you may have to pay the Part B deductible and/or coinsurance (your
share of the cost) for the office visit or if you get these services in the same visit

as other services. If you’re in a Medicare Advantage Plan (like an HMO or
PPO), your costs may be different. Check with your plan to find out about these
costs.
 Screenings and Other Services: You don’t have to pay the Medicare Part
B deductible or copayment for these screenings if certain coverage
criteria are met:
o Bone mass measurement
o Cervical cancer screening, including Pap tests and pelvic exams
o Cholesterol and other cardiovascular screenings
o Colorectal cancer screening (except for barium enemas)
o Diabetes screening
o Flu, pneumonia, and hepatitis B vaccinations
o HIV screening
o Mammograms
o Medical nutrition therapy to help people manage diabetes or kidney
disease
o Prostate cancer screening (except digital rectal examinations)
o See the full list of covered preventive services at Medicare.gov
 Tobacco Use Cessation Counseling: This benefit is considered a covered
preventive service if you have not been diagnosed with an illness caused
or complicated by tobacco use. If you have already been diagnosed with a
tobacco related illness, the Part B deductible and/or coinsurance may
apply.

Medicare Drug Discounts
The Affordable Care Act has made Medicare drug coverage more affordable
with the gradual closing of the coverage gap (known as the “donut hole”). If

you reach the “donut hole” in 2015, you will get a 55 percent discount on
covered brand name drugs and a 35 percent discount on generic drugs.
Nationally, 9.4 million people with Medicare have saved over $15 billion on
prescription drugs since the law’s enactment, for an average savings of $1,598
per person.
And thanks to the health care law, coverage for both brand name and generic
drugs will continue to increase over time until the coverage gap is closed in
2020.
See the schedule below for information on what you’ll pay for drugs while
you’re in the coverage gap:
o 2015: 45% for brand-names and 65% for generics
o 2016: 45% for brand-names and 58% for generics
o 2017: 40% for brand-names and 51% for generics
o 2018: 35% for brand-names and 44% for generics
o 2019: 30% for brand-names and 37% for generics
o 2020: 25% for brand-names and 25% for generics
You don’t need to do anything to get the discount. If you reach the coverage gap
and you don’t get a discount when you pay for your brand-name prescription,
you should review your next Explanation of Benefits (EOB) notice. You can
work with your drug plan to make sure that your drug records are correct.

Strengthening Medicare
Here are some other ways we’re improving how Medicare works:
 Fighting Medicare Fraud
We’re taking strong action to reduce payment errors, waste, fraud, and abuse in
Medicare. The health care law helps stop fraud with tougher screening
procedures, stronger penalties, and new technology.
Over the last five years, fraud enforcement efforts have recovered $19.2 billion
from fraudsters. For every dollar spent on health care-related fraud and abuse
activities in the last three years, we’ve recovered $8.10.

 Higher Quality Care
The coordination of care between doctors and the overall quality of care will
improve so you’re less likely to experience readmission to the hospital and other
preventable harms. Hospitals have new, strong incentives to improve your
quality of care. With new initiatives to support care coordination, your doctor
may get additional resources to make sure that your care best meets your needs.

 Medicare Advantage Plans
The health care law offers additional protections for Medicare Advantage Plan
members and Prescription Drug Plan members by taking strong steps that limit
the amount these plans spend on administrative costs, insurance company
profits, and things other than health care.
Medicare is stronger today thanks to the Affordable Care Act. In 2014, the
Medicare Trustees projected that the Medicare Trust fund financing Medicare’s
hospital insurance coverage will remain solvent until 2030, four years beyond
what was projected in the 2013 report. Just a few years ago, the Medicare Trust
fund was projected to run out of money by 2017.

The Affordable Care Act and Young Adults
The Affordable Care Act is working in terms of affordability, access, and quality
for young adults. This includes young adults who were previously uninsured
and young adults who had insurance that didn't provide them with adequate
coverage and financial security. Middle-class young adults have more security,
and many of those who already had insurance now have better coverage. Fewer
young adults are uninsured than before the Affordable Care Act. At the same
time, as a country, we're spending our health care dollars more wisely and we're
starting to receive higher quality care.
Health insurance coverage is now more affordable and accessible for millions of
Americans. The Affordable Care Act invests in prevention and wellness, and
gives individuals and families more control over their care. In addition, the law
addresses disparities in access to quality, affordable health coverage.

Addressing Health Disparities and Improving Access
Young adults have traditionally been the age group most likely to be uninsured.
 Before the Affordable Care Act, privately insured young adults were
more than twice as likely as older adults to lose their insurance coverage
in the course of a year, often because they aged off of their parent’s plan,
graduated from school, or changed jobs.
Before the Affordable Care Act, many young adults may not have been able to
find affordable coverage because of a pre-existing condition.
 Up to 30 million 18-34 year olds have a pre-existing condition, which
means that before the Affordable Care Act they could have been charged
higher premiums or denied coverage altogether.
While young adults are generally healthier than the overall population, they are
at elevated risk of a variety of health and safety risks.
 Young adults have the highest rates of injury and death from motor
vehicle accidents, homicide, substance abuse, sexually transmitted
infections, and mental health problems
 An estimated 12 million individuals between the ages of 5 and 22 years
suffer a sports related injury annually. For those without health insurance,
these injuries can be very expensive. A sprained ankle can cost $2,290,
and charges for a broken arm average nearly $7,700

Getting Covered
Beginning in 2010, the Affordable Care Act required that all insurers offering
dependent coverage allow young adults to stay on their parent’s plans until age
26, and Americans of all ages now have affordable new options to obtain
coverage through the Health Insurance Marketplace or through Medicaid.
From the time the Affordable Care Act’s dependent coverage provision took
effect in 2010 through the first quarter of 2014, the uninsurance rate among
individuals ages 19 to 25 fell by 13.2 percentage points, a nearly 40 percent
decline. In detail:
 Immediately after the Affordable Care Act’s dependent coverage
provision took effect, 3.1 million young adults gained health coverage.

 Since the opening of the Marketplace, more than 10 million Americans
have gained insurance coverage, reducing the number of uninsured by 26
percent in just one year. The age group with the largest coverage gains
was 18-34 year olds.6
 2.2 million people who selected a plan on through the Marketplace during
the initial open enrollment period were young adults between the ages of
18 and 34. A total of 2.7 million were between the ages of 0 and 34.7
Young adults may have been motivated to enroll in coverage in 2014 in part due
to the financial assistance available through the Marketplace. Nearly 5 in 10
uninsured young adults who were eligible could have gotten covered for $50 or
less per month and nearly 7 in 10 could have gotten covered for $100 or less
after tax credits.8 In fact, among all people who actually selected plans with
premium tax credits through the Federally-facilitated Marketplace, nearly half
had monthly premiums of $50 or less and more than 7 in 10 had premiums $100
or less after tax credits.9
Young adults have access to health insurance that fits their needs and budget
through the Marketplace. All plans in the Marketplace cover essential health
benefits, pre-existing conditions, recommended preventive care and more. Open
enrollment begins November 15, 2014 and ends on February 15, 2015. Enroll
by December 15, 2014 for coverage that starts January 1, 2015.
Research has found benefits for young adults who gain coverage:
 Young adults who gain coverage are less likely to face large out-ofpocket medical expenses and less likely to delay or forgo care due to
cost.10
 Several studies also indicate that newly-insured young adults are more
likely to receive several types of inpatient and outpatient care, including
preventive care like blood pressure screening, cholesterol screening, and
routine physical and dental examinations.11 Another study found that
newly insured young adults are more likely to report being in excellent
health.12
 Expanded access to coverage in young adulthood may also have big
benefits for workers’ careers, by allowing workers to obtain additional
schooling and choose the jobs that best match their career goals.13
There has also been a striking slowdown in the growth of health care costs, and
the evidence shows that the Affordable Care Act is contributing to that

slowdown.14 Slower growth in health costs for employers may ultimately be
passed through to workers as higher wages, so the Affordable Care Act may
help to drive faster growth in take-home pay for today’s young adults relative to
their predecessors.

The Affordable Care Act and African Americans

The Affordable Care Act is working in terms of affordability, access, and
quality for African American families, seniors, businesses, and taxpayers. This
includes African Americans who were previously uninsured and African
Americans who had insurance that didn't provide them with adequate coverage
and financial security. African American families have more security, and many
of those who already had insurance now have better coverage. Fewer Americans
are uninsured. At the same time, as a country, we're spending our health care
dollars more wisely and we're starting to receive higher quality care.
Health insurance coverage is now more affordable and accessible for millions of
Americans. The Affordable Care Act invests in prevention and wellness, and
gives individuals and families more control over their care. In addition, the law
addresses disparities in access to quality, affordable health coverage.

Addressing Health Disparities

African Americans suffer from several illnesses at higher rates than nonHispanic white Americans:
 They have the highest mortality rate of any racial and ethnic group for
cancer generally and for most major cancers individually, including
stomach, liver, prostate, and colon cancers1.
 Even though the rate of breast cancer incidence is 10 percent lower
among African American women, they are 40 percent more likely to die
from the disease2. Earlier screening and detection for African American
women could help reduce this death rate.

 Although African American adults are 40 percent more likely to have
high blood pressure3, they are 18 percent less likely than their nonHispanic white counterparts to have their blood pressure under control4.
 African American adults are less likely than non-Hispanic white adults to
have received the flu vaccine in the past year5.
 African American adults are also twice as likely to be diagnosed with
diabetes6.
 The infant mortality rate among African Americans is 2.3 times that of
non-Hispanic whites, and African American infants are 4 times more
likely than non-Hispanic white infants to die due to complications related
to low birthweight7.
At the same time, African-Americans are 55 percent more likely to be uninsured
than white Americans. In 2013, the proportion of African Americans who were
uninsured was 17 percent8.
Millions of African Americans across the country are already benefiting from
the stronger coverage and consumer protections made possible by the
Affordable Care Act:
 7.8 million African Americans with private insurance now have access to
expanded preventive services with no cost-sharing. This includes services
such as colonoscopy screening for colon cancer, Pap smears and
mammograms for women, well-child visits, and flu shots for all children
and adults.

 Private plans in the Health Insurance Marketplace are required to cover
10 essential health benefit categories, including maternity and newborn
care. Over 390,000 African American women in the individual market
alone are projected to gain maternity coverage thanks to the Affordable
Care Act.
 An estimated 5.1 million African American women with private health
insurance now have guaranteed access to women’s preventive services
without cost-sharing. These services include well-woman visits, HPV
testing, breastfeeding support and counseling, mammograms and
screenings for cervical cancer, prenatal care, and other services.

 More than 500,000 African American young adults between ages 19 and
26 who would have been uninsured, including 230,000 African American
women, now have coverage under their parents’ employer-sponsored or
individually purchased health insurance plan.
 About 10.4 million African Americans, including 3.9 million adult
African American women, no longer have lifetime or annual limits on
their health insurance coverage thanks to the Affordable Care Act.
 Nearly eight million African Americans with a preexisting health
condition9 are no longer at risk of being denied coverage since the ACA
prohibits insurers from denying someone coverage or charging them
more because of a pre-existing condition.
 Major federal investments in quality of care are improving management
of chronic diseases that are more prevalent among African Americans.

 The health care workforce is more diverse due to a more than doubling of
the National Health Service Corps. African American physicians make up
about 18 percent of Corps physicians, a percentage that greatly exceeds
their 6 percent share of the national physician workforce.

 Investments in data collection and research will help us better understand
the causes of health care disparities and develop effective programs to
address them.

 The $11 billion in the Affordable Care Act for the nearly 1,300
community health centers has increased the number of patients served by
nearly 5 million. Nearly one of every four patients at a health center is
African American.

Getting Covered

 As of June 2014, 1.7 million African Americans (ages 18-64) gained
health insurance coverage since the start of the Affordable Care Act initial
open enrollment period in October 2013, a 6.8 percentage point drop in
the uninsured rate over that period.

 Consumers have access to health insurance that fits their needs and
budget through the Health Insurance Marketplace. All plans in the
Marketplace cover essential health benefits, pre-existing conditions,
recommended preventive care and more. Open enrollment begins
November 15, 2014 and ends on February 15, 015. Enroll by December
15, 2014 for coverage that starts January 1, 2015.

 Enrollment in Medicaid and the Children's Health Insurance Program
(CHIP) is open year round. And so far, twenty-seven states and
Washington, D.C. have expanded Medicaid. If all states took advantage
of new opportunities to expand coverage under the Medicaid program, 95
percent of eligible uninsured African Americans might qualify for
Medicaid, CHIP, or programs to help lower the cost of their Marketplace
coverage.

 Nearly two thirds (62 percent) of uninsured African Americans have
incomes at or below the Medicaid expansion limit of 138 percent of
federal poverty level10. However, nearly six in ten uninsured African
Americans with incomes below the Medicaid expansion limit reside in
states that were not planning to expand Medicaid as of late June 201311.

The Affordable Care Act and Asian Americans, Native Hawaiians, and
Pacific Islanders

The Affordable Care Act is working in terms of affordability, access and quality,
for Asian American, Native Hawaiian, and Pacific Islander families, seniors,
businesses and taxpayers. This includes those who were previously uninsured
and those who had insurance that didn’t provide them with adequate coverage
and financial security.
Asian American, Native Hawaiian, and Pacific Islander families have more
security, and many of those who already had insurance now have better
coverage. Fewer Americans are uninsured. At the same time, as a country, we’re
spending our health care dollars more wisely and we’re starting to receive
higher quality care.
Health insurance coverage is now more affordable and accessible for millions of
Americans. The Affordable Care Act invests in prevention and wellness, and
gives individuals and families more control over their care. In addition, the law
addresses disparities in access to quality, affordable health coverage.

Addressing Health Disparities

Asian Americans, Native Hawaiians, and Pacific Islanders are less likely than
other groups to get screened for cancer1. For example, in 2010, Asian American
women over 18 years of age were the least likely to have had a Pap test (68.0
percent) compared with other women: non-Hispanic white (72.8 percent), nonHispanic black (77.4 percent), Hispanic/Latino (73.6 percent), American
Indian/Alaska Native (73.4 percent).
Additionally, in 2008, Asian Americans and Pacific Islanders ages 19 through
24 were 1.6 times more likely to have Hepatitis B than non-Hispanic whites 2.
Expanding access to coverage can be an effective strategy for reducing
disparities.
Millions of Asian Americans, Native Hawaiians, and Pacific Islanders across the
country are already benefiting from the stronger coverage and consumer
protections made possible by the Affordable Care Act:

 4.3 million Asian Americans with private insurance now have access to
expanded preventive services with no cost-sharing. This includes services
such as colonoscopy screening for colon cancer, Pap smears and

mammograms for women, well-child visits, and flu shots for all children
and adults.

 Private plans in the Marketplace are required to cover 10 essential health
benefit categories, including maternity and newborn care. Over 208,800
Asian Americans in the individual market alone are projected to gain
maternity coverage under the Affordable Care Act.

 An estimated 2.5 million Asian American women with private health
insurance now have guaranteed access to women’s preventive services
without cost-sharing. These services include well-woman visits, HPV
testing, breastfeeding support and counseling, mammograms and
screenings for cervical cancer, prenatal care, and other services.

 121,000 Asian American young adults between ages 19 and 26 who
would have been uninsured, including 53,000 Asian American women,
now have coverage under their parent’s employer-sponsored or
individually purchased health insurance plan.

 About 5.5 million Asian Americans, including 2.1 million adult Asian
American women, no longer have lifetime or annual limits on their health
insurance coverage thanks to the Affordable Care Act
.
 Major federal investments in quality of care are improving management
of chronic diseases that are more prevalent among Asian Americans and
Pacific Islanders.

 Investments in data collection and research will help us better understand
the causes of health care disparities and develop effective programs to
address them.

 The $11 billion in the Affordable Care Act for nearly 1,300 community
health centers has increased the number of patients served by nearly 5
million. Health centers provide culturally competent and linguistically
appropriate care.

Getting Covered
 Consumers have access to health insurance that fits their needs and
budget through the Health Insurance Marketplace. All plans in the
Marketplace cover essential health benefits, pre-existing conditions,
recommended preventive care and more. Open enrollment begins
November 15, 2014 and ends on February 15, 2015. Enroll by December
15, 2014 for coverage that starts January 1, 2015.

 Enrollment in Medicaid and the Children’s Health Insurance Program
(CHIP) is open year round. Members of immigrant families lawfully
residing in the United States may qualify for Medicaid and CHIP
coverage, if they meet the eligibility criteria in that state; if they don’t,
they may qualify for Marketplace coverage and assistance. And so far,
twenty-seven states and Washington, D.C. have expanded their Medicaid
programs to extend eligibility to more individuals. If all states took
advantage of new opportunities to expand Medicaid coverage under the
Affordable Care Act, 90 percent of eligible uninsured Asian Americans
and Pacific Islanders might qualify for Medicaid, CHIP, or tax credits to
help with the cost of premiums in the Marketplace.

 Many immigrant families are of “mixed status,” with members having
different immigration and citizenship statuses. “Mixed status” families
can apply for Medicaid and CHIP or for coverage through the
Marketplace, where dependent family members may be eligible for
programs that help lower the cost of Marketplace health insurance

coverage. People without lawful immigration status are not eligible to
enroll in the Marketplace. Medicaid provides payment for treatment for
an emergency medical condition for individuals who do not meet the
citizenship or immigration status requirements for Medicaid and are
otherwise eligible for Medicaid in the state. It is important to note that
information provided by applicants or beneficiaries won’t be used for
immigration enforcement purposes. Also, applying for Medicaid or
CHIP, or getting help with health insurance costs in the Marketplace, does
not make someone a “public charge” and will not affect someone’s
chances of becoming a Lawful Permanent Resident or U.S. citizen.

 Many immigrant families are of “mixed status,” with members having
different immigration and citizenship statuses. “Mixed status” families
can apply for Medicaid and CHIP or for coverage through the
Marketplace, where dependent family members may be eligible for
programs that help lower the cost of Marketplace health insurance
coverage. People without lawful immigration status are not eligible to
enroll in the Marketplace. Medicaid provides payment for treatment for
an emergency medical condition for individuals who do not meet the
citizenship or immigration status requirements for Medicaid and are
otherwise eligible for Medicaid in the state. It is important to note that
information provided by applicants or beneficiaries will not be used for
immigration enforcement purposes. Federal and state Marketplaces and
state Medicaid and CHIP agencies cannot require applicants to provide
information about the citizenship or status of any family or household
member who is not applying for coverage. Therefore, mixed status
families should not be afraid to enroll their family members in coverage.
Also, applying for Medicaid or CHIP, or getting help with health
insurance costs in the Marketplace, does not make someone a “public
charge.” And it will not affect their chances of becoming a Lawful
Permanent Resident or U.S. citizen.

The Affordable Care Act and Women
The Affordable Care Act is working in terms of affordability, access, and quality
for women. This includes women who were previously uninsured and those
who had insurance that didn't provide them with adequate coverage and
financial security. Middle-class women have more security, and many of those
who already had insurance now have better coverage. Fewer women are

uninsured than before the Affordable Care Act. At the same time, as a country,
we're spending our health care dollars more wisely and we're starting to receive
higher quality care.
Health insurance coverage is now more affordable and accessible for millions of
American women. The Affordable Care Act invests in prevention and wellness,
and gives individuals and families more control over their care. In addition, the
law addresses disparities in access to quality, affordable health coverage.

Background on Women’s Health in America
Women have unique, and sometimes costly, health and medical needs.
 Some disease and health conditions, such as cardiovascular disease and
cancer, affect women at roughly the same rates as men. Women also have
special needs related to the health conditions that affect their reproductive
organs such as breast, uterine, and cervical cancer.

 Prenatal care and delivery, while essential to the health of both mother
and baby, are nonetheless expensive, coming at an average cost over
$20,000 in 2011 for an uncomplicated birth.1

Women are more likely to live in poverty at all ages, but differences are
especially pronounced in middle and older ages.2
 Among adults ages 18-64, the poverty rate for women was 15.3 percent
compared to 11.8 percent for men.

 Among adults 65 and older, women are almost twice as likely to be in
poverty: 11.6 percent of women and 6.8 percent of men.
Before the Affordable Care Act, women faced unique challenges in the health
insurance market.

 In 2012, a 25-year-old woman could be expected to pay 81 percent more
for health insurance than a man, even for a policy that did not include
maternity coverage.
3

 Prior to Affordable Care Act, 92 percent of health insurance plans in the
individual market were gender-rated, for example, charging 40-year-old
women more than 40-year-old men for coverage.4

 In 2011, 62 percent of individual market enrollees did not have maternity
coverage.5

 Women are more likely to be covered as dependents, which made them
more vulnerable to losing their insurance coverage prior to the Affordable
Care Act.6

Improved Benefits
Affordable Care Act

for

Women

under

the

Under the Affordable Care Act, women can no longer be charged more than
men for health insurance premiums or denied coverage for pre-existing
conditions, and the Affordable Care Act gives women access to maternity
benefits and preventive services.
 Private plans in the Health Insurance Marketplace as well as most
individual and small group plans outside the Marketplace are now
required to cover 10 essential health benefit categories, including
maternity and newborn care. An estimated 8.7 million American women
with individual insurance coverage gained coverage for maternity
services because of the health care law.

 An estimated 48.5 million women with private health insurance are
benefiting from recommended preventive services with no cost sharing,
including mammograms, cervical cancer screenings, prenatal care, flu

and pneumonia shots, and regular well-baby and well-child visits. Almost
30 million of those women did not have access to preventive services
without cost-sharing before the Affordable Care Act. The Affordable Care
Act also now requires most health plans to cover additional preventive
services with no cost-sharing, such as well-woman visits, screening for
gestational diabetes, domestic violence screening, breastfeeding supplies
and contraceptive services.7
Improvements to Medicare under the Affordable Care Act are particularly
beneficial to women.
 Women make up more than half of the Medicare population (56.9
percent).

 Under the Affordable Care Act, the 26.8 million women who have
coverage through Medicare now receive preventive services without costsharing including the annual wellness visit, a personalized prevention
plan, mammograms, and bone mass measurement for women at risk of
osteoporosis.8
Additionally, millions of women across the country are benefiting from the
better coverage and consumer protections made possible by the Affordable Care
Act:
 During the first annual enrollment period, more than 8 million Americans
signed up for coverage through the Health Insurance Marketplace,
including more than 4.3 million women.

 1.1 million women between ages 19 and 25 who would have been
uninsured now have coverage under their parent’s employer-sponsored or
individually purchased health insurance plan.

 Nearly 40 million women no longer face lifetime limits on their health
coverage.

 As many as 65 million women with pre-existing conditions can no longer
be discriminated against or charged higher premiums for their health
coverage.

 Enrollment in Medicaid and the Children’s Health Insurance Program is
open year round and is providing comprehensive coverage for lower
income women who were previously only eligible for coverage while
pregnant, thanks to the Medicaid expansion.

The Affordable Care Act and American Indian
and Alaska Native People
The Affordable Care Act will help make health insurance coverage more
affordable and accessible for millions of Americans. For American Indians and
Alaska Natives, the law will address inequities and increase access to quality,
affordable health coverage, invest in prevention and wellness, and give First
American individuals and families more control over their care.
At the Department of Health and Human Services (HHS), tribal consultation is
a critical ingredient of a sound and productive Federal-tribal relationship, and
crucial to the successful implementation of the Affordable Care Act.
Consultation and outreach efforts provide education and information about the
law and how it will impact Indian Country while ensuring policies and
programs are responsive to feedback from tribal communities.
The Affordable Care Act will provide 579,000 uninsured American Indians and
Alaska Natives an opportunity to get affordable health insurance coverage. The
following provides an overview of the coverage and benefits available to
American Indians and Alaska Natives today and those made possible beginning
in 2014 by the Health Insurance Marketplace.
Happening Now: Improving Health Care for American
Indians and Alaska Natives
 The Affordable Care Act permanently reauthorizes the Indian Health Care
Improvement Act (IHCIA) and authorizes new programs to ensure that
the Indian Health Service (IHS) is more equipped to meet its mission to

raise the health status of American Indians and Alaska Natives to the
highest level.

 Tribes or tribal organizations carrying out a program under the Indian
Self-Determination and Education Assistance Act or urban Indian
organizations carrying out a program under Title V of IHCIA may now
purchase coverage for their employees from the Federal Employees
Health Benefits Program (FEHB). As of July 31, 2013, over 10,000
employees from 53 tribes in 15 states are enrolled in the FEHB. Ten
additional tribes have expressed interest, representing approximately
2,000 additional employees.



IHS and Tribal programs are now starting to receive reimbursement
payments from the Department of Veterans Affairs (VA) for direct care
services provided to eligible veterans under the IHS VA reimbursement
agreement signed as a result of a new authority in the Indian Health Care
Improvement Act.

 Targeted interventions, such as Community Transformation Grants,
promote healthy lifestyles, lower health care costs, and reduce health
disparities in tribal communities. Major investments to improve quality of
care are improving management of chronic diseases that are more
prevalent among American Indians and Alaska Natives.

 Over the last three years, the IHS has supported the National Indian
Health Outreach and Education (NIHOE) project, an effort involving the
National Congress of American Indians, the National Indian Health
Board, and the National Council of Urban Indian Health and 11 regional
entities, primarily Regional Tribal Health Boards, to conduct area specific
outreach and education regarding the Affordable Care Act. As of May
2013, the NIHOE project has completed over 330 trainings with tribes,
tribal organizations, and urban Indian health programs.

Coming Soon: Better Access to Coverage for
American Indians and Alaska Natives

 579,000 uninsured American Indians and Alaska Natives will have new
opportunities for coverage through the Health Insurance Marketplace. As
many as nine out of 10 of those may qualify for financial assistance either
through tax credits to purchase coverage in the Marketplace, cost-sharing
reductions that will reduce or eliminate out of pocket costs, or through
Medicaid if their state expands eligibility.

 American Indians and Alaska Natives will be eligible to purchase
coverage through the new Health Insurance Marketplace. The
Marketplace is a destination where consumers can compare health
insurance options in simple, easy-to-understand language. At the
Marketplace, consumers will be able to compare insurance options based
on price, benefits, quality and other factors with a clear picture of
premiums and cost-sharing amounts to help them choose the insurance
that best fits their needs.

 American Indians and Alaska Natives earning between 100 percent of the
federal poverty level (FPL) (or $23,550 for a family of four in 2013,
$29,440 in Alaska) and 400 percent of FPL (or $94,200 for a family of
four in 2013, $117,760 in Alaska) may be eligible for advance premium
tax credits that lower monthly premiums right away. Others may be
eligible for free or low cost coverage from the Health Insurance
Marketplace.

 Certain American Indians and Alaska Natives who purchase health
insurance through the Marketplace do not have to pay co-pays or other
cost-sharing if their income is under 300 percent of FPL, which is
roughly $70,650 for a family of four in 2013 ($88,320 in Alaska). In
addition, certain American Indians and Alaska Natives will have access to
special monthly enrollment periods so they may get insurance outside the
yearly open enrollment period.

 Many American Indians and Alaska Natives will be newly eligible for
Medicaid under the Affordable Care Act. States have new opportunities
to expand Medicaid coverage to include Americans with family incomes
at or below 133 percent of the federal poverty level (generally $31,322
for a family of four in 2013). This expansion includes adults without
dependent children living at home, who have not previously been eligible
in most states.

 All American Indians and Alaska Natives who are eligible to receive
services from an Indian health care provider (as defined in 42 C.F.R. §
447.50) may receive an exemption from the shared responsibility
payment if they do not maintain minimum essential coverage under the
Affordable Care Act. Prior to HHS’ announcement of the exemption, only
a portion of the American Indian and Alaska Native population –
members of federally recognized tribes – would have access to such an
exemption. The exemption reflects comments and feedback received
from Indian Country through rulemaking and the tribal consultation
process.

 With greater numbers of American Indians and Alaska Natives with some
form of coverage, including Medicaid, the Children’s Health Insurance
Program (CHIP) and private insurance, IHS will be better able to provide
needed health services. This coverage will improve reimbursements to
IHS and will also benefit Indian health programs.

The Affordable Care Act- What it Means for Rural America
The Affordable Care Act will help make health coverage affordable and
accessible for millions of Americans, starting on October 1, 2013. For the
nearly 60 million Americans living in rural areas, the law will address inequities
in the availability of health care services, increase access to quality, affordable
health coverage, invest in prevention and wellness, and give individuals and
families more control over their health care.

Rural Americans experience higher rates of chronic disease, disability and
mortality. But help is on the way. Learn how the Affordable Care Act offers
important reforms to improve the health of rural communities.

Key Facts Regarding Rural Coverage in the Health
Insurance Marketplace:
Beginning in 2014, we estimate that through the Affordable Care Act, more than
7.8 million uninsured rural Americans under age 65 with new opportunities to
enroll in affordable health care. Consider these numbers:
 Nearly one in five uninsured Americans lives in a rural area.
 A greater proportion of rural residents lacks health insurance in
comparison to urban residents.
 Due to lower income levels, a large segment of the rural population will
be eligible for subsidized insurance coverage through the Health
Insurance Marketplaces (Marketplaces)
 The Health Insurance Marketplaces are expected to increase competition
in the insurance market in rural areas – especially in the 29, mostly rural
states, where a single insurer currently dominates more than half the
health insurance market.
 In states that are expanding Medicaid, rural residents are more likely to
be eligible for affordable coverage under the coverage expansion.
By increasing competition, the Marketplace will help lower costs. . This is
especially important in rural areas, where studies show that one in five farmers
face medical debt and families, on average, pay nearly half of their health care
costs out-of-pocket.

What the Healthcare Law Means for Rural Communities:
Uninsured individuals living in rural areas will now be able to use the
Marketplaces to compare qualified health plan insurance options based on price,
benefits, quality, and other factors with a clear picture of premiums and costsharing amounts to help them choose the qualified health insurance plan that

best fits their needs. Each insurance plan offered through the Marketplaces will
cover essential health benefits, including prescription drugs, inpatient and
emergency services, pediatric care, and behavioral health treatment.
The Marketplaces and new coverage options build on a number of insurance
benefits already in place for rural Americans from the Affordable Care Act:
 The 30 million rural Americans with private insurance now have access
to expanded preventive services with no cost sharing. These services
include well-child visits, blood pressure and cholesterol screenings, Pap
tests and mammograms for women and flu shots for children and adults.

 The more than 11 million elderly and disabled rural Americans who
receive health coverage from Medicare also have access to many
preventive services with no cost sharing, including annual wellness visits
with personalized prevention plans, diabetes and colorectal cancer
screening, bone mass measurement, and mammograms.

 It is estimated that nearly 600,000 young rural Americans between ages
19 and 26 now have coverage under their parent’s employer-sponsored or
individually purchased health plan.

 Lifetime limits can no longer be included in private insurance policies,
and annual limits cannot be less than $2,000,000. Annual limits are
prohibited beginning in 2014.

 Children (under age 19) cannot be denied coverage, because of a preexisting condition. This protection will be extended to adults in 2014.

Where Rural Americans Can Go for Consumer Assistance:

Individuals and families shopping on the Marketplaces can benefit from a range
of consumer assistance programs, including Navigators, non-Navigator
assistance personnel, certified application counselors, licensed agents and
brokers, and outreach and enrollment counselors at more than 1,100 health
centers nationwide. A total of $5.5 million in Navigator funding went to
organizations that focus on rural issues and also receive grants through the
Federal Office of Rural Health Policy (ORHP) which focuses on rural health.
In addition, the ORHP has made almost $1.3 million available to support 52
rural community and health care organizations to provide outreach and
assistance to the uninsured in rural areas. Furthermore, through $1.25 million
in funding provided by the Centers for Medicare & Medicaid Services, a
network of Cooperative Extension Service educators in 12 states will help
uninsured and underinsured consumers make informed decisions about
participating in the Marketplaces.
The Department of Health and Human Services operates a 24/7 call center to
assist consumers in more than 150 languages. Consumers also have access to
an online, live chat available on www.healthcare.gov which will connect them
to a customer service representative able to answer a range of questions. These
resources for consumer assistance may be especially useful in rural areas where
there is less broadband access and lower population density. The contact
information is provided below.
The Federal Office of Rural Health Policy is holding weekly webinars to make
rural health care stakeholders aware of new opportunities for coverage through
the Affordable Care Act. These sessions provide a forum for rural providers and
health care organizations to share best practices, ask questions, and learn more
about resources for consumer outreach and education.
How Obamacare Will Affect Social Security and People With Disabilities
One way that Obama's health care reform will help make health insurance
accessible to more people is by eliminating preexisting condition exclusions.
This will be a big benefit to those with disabilities, because many will now be
able to purchase their own insurance. Having more people eligible for private
health insurance will have an effect on Social Security, Medicare, and Medicaid.
Thanks to Obama's health care reform law, as of January 1, 2014, insurance
companies can no longer deny coverage to individuals with preexisting
conditions, or charge them higher rates. (See Nolo’s recent article on the ban
against preexisting condition limitations.) At the same time, individuals without
group health insurance can purchase insurance through the Health Insurance

Marketplace; applications can be submitted starting October 1, 2013. Those
with low income (less than 400% of the federal poverty level) are eligible for
lower premiums, and those with even lower income (250% of the federal
poverty level) can qualify for lower out-of-pocket costs like deductibles and
copays. (See Nolo's federal poverty guidelines for exact figures.)
These two provisions of the new health care reform law (called the Patient
Protection and Affordable Care Act of 2010) should lower the number of people
on Medicare and Social Security disability. Why? Historically, many folks with
preexisting conditions who lost their prior work-based health coverage apply for
disability benefits just so they can get health care benefits. They know that an
approval for Social Security disability will mean they can either qualify early
for Medicare, or, if they have very low income (or somewhat low income and
very high medical expenses), they may be eligible for Medicaid. Some of these
folks will now decide not to file for disability benefits since they don’t need a
disability approval to get health care, now that insurance companies can’t turn
down people with disabling medical conditions and disabled individuals have an
opportunity to buy affordable health care, more flexibility in choosing a health
care plan, and the potential for out-of-pocket savings on their health care needs.
Not only that, but now that more persons with disabilities or chronic medical
conditions will have good health care and access to reasonable priced
medications, more of them will be able to work despite having physical or
mental impairments, and fewer of them will need to apply for disability
benefits.
What's more, those who can’t work for a while due to a temporary disability
will be less likely to need to be off work indefinitely, thanks to better health care
and access to medications. In fact, fewer people many now qualify for Social
Security disability since only those whose medical conditions prevent them
from working for at least 12 months are eligible for SSDI or SSI disability
benefits. Now, some disability applicants who would have been eligible to
receive Social Security while they recuperate from injuries or mental illnesses
may recover sooner because of regular doctors’ visits plus the proper
medication.
On the other hand, some other folks who would have previously been denied
disability benefits or Medicaid benefits are now more likely to be approved.
Often disability applicants are denied because they haven’t been seeing a doctor
for treatment and don’t have test results to prove their disability. Now that
health care is more accessible, more folks who apply for disability will have
been seeing doctors regularly and have the proper diagnoses, lab results, and xrays in their records. This should help eliminate the need for Social Security to
send applicants to consultative medical exams and should reduce the number of
disability appeals – with the proper medical records, fewer claims will be

incorrectly denied disability benefits in the first place. This represents
significant potential cost savings for Social Security.
Similarly, despite fewer people applying for disability benefits, Medicaid roles
will increase, of course, because in some states Obamacare’s Medicaid
expansion will now allow adults with incomes of up to 133%-138% of the
federal poverty level to qualify for Medicaid.
But overall, health care reform appears to be a great deal for persons with
disabilities.

How Does Obamacare Affect Doctors, Nurses and Hospitals?

The Affordable Care Act, also known as Obamacare, receives a lot of
attention in relation to how it affects individuals. This law requires most
Americans to obtain healthcare coverage, either through employment or through
a private or network plan. While the focus is on the individual, other entities are
affected as well. How does Obamacare affect doctors? This new U.S. law
affects a variety of people and businesses and in several ways. Consumers are
asking questions about whether they can keep their current doctors. Some
doctors wonder what this means to their patient load, income, and the overall

health of their practice. It's important to break down the various ways the law
affects doctors and patients alike.

What Does Obamacare Mean for Doctors Themselves?
In many instances, the Affordable Care Act may help doctors. Millions of
Americans were without health insurance prior to passage of the ACA. The the
new law enables individuals to get the coverage they need to actually receive
healthcare. Most doctors want patients to be seen. This increases the number of
people who are likely to seek medical care when they need it. Prior to the law's
passage, many men, women, and children went without care because they could
not afford it.
As a result, the passage of Obamacare means doctors are likely to experience an
increase in the number of patients they see. Customer counts, so to speak, are
likely to rise. It's also important to note that only a few doctors are associated
with some of the limited networks available through the new law. This could
lead to a shortage of doctors available to some patients and too many patients
for the doctors in such networks.

What Does Obamacare Mean for Physicians in Relation to
Patient Decisions?
According to the National Physicians Alliance, a few key factors will play a
role in patient care now that Obamacare is in place. Doctors and patients are
affected in these ways:
 The law prohibits denial of care for and discrimination against patients
with pre-existing conditions This means doctors have the ability to treat
patients who might otherwise have been unable to seek medical attention
due to inability to qualify for medical coverage.
 Without lifetime limits on insurance coverage, doctors can provide more
thorough examinations, tests and screenings as a step towards diagnosis
or treatment of the patient.
 Patients may no longer have to wait until next year to get the care they
need. Obamacare eliminates annual limits on insurance, so doctors will
no longer have to wait to see patients who previously would have had to
wait until the following year to access new medical coverage limits

.

What Does Obamacare Mean Financially for Doctors and Their
Practices?
Some reports indicated that doctors would see lower payments once Obamacare
went into effect. Yet this may not be the case. In some instances, Obamacare
may lead to improved financials. One key reason for this is that Medicare pays a
10% bonus for primary care services and a 10% bonus to general surgeons in
areas with a shortage.
Doctors with small practices can also save money, like most other businesses,
by shopping for insurance for their employees through the health insurance
marketplace, potentially decreasing costs. The marketplace allows small
practices to join together to shop for such coverage.

Accountable Care Organizations May Limit Solo Practices
Many hospitals began purchasing smaller doctor practices prior to Obamacare
going into effect. This was because the new law endorses Accountable Care
Organizations, which bring together smaller practices. Many solo practices have
worked to move towards larger ones, mainly because the cost of implementing
policies and procedures under the new law is burdensome. This includes
increasing regulations, the use of new electronic health records and shifting
referral patterns.
Some doctors believe this is bad for business, citing a similar trend toward
hospitals buying out doctors that occurred in the 1990s. Doctors working as
employees of hospitals are likely to work less, leading to decreases in wages
due to lower productivity. This kind of consolidation is not always beneficial to
the finances of doctors.

Even More Changes Expected for Doctors

Obamacare will impact doctors in many other ways. What are the more general
impacts of the new law?
 Doctors will be likely to spot health problems early, due to patients
coming in for the annual physicals made available to them by their
newfound healthcare coverage.
 Doctors must make the transition to electronic medical records. Though
many practices have made this move already, those that have held off will
need to make the investment and switch now. Some financial incentives
are in place to help with this switch. Nevertheless, the process is timeconsuming and very expensive, making it a financial strain on older
doctors with extensive medical records.
 Doctors will be able to continue providing care for children who have
chronic ailments. Previously, many children with these conditions
reached their lifetime maximum insurance payments very early on,
leading to limited medical access once benefits ran out. With the removal
of a lifetime cap, this is no longer a concern.
In short, doctors will see patients more often, potentially spotting medical
conditions sooner. New regulations and electronic records are likely to add to
the cost of doing business. And, in some cases, doctors who fail to provide
adequate care may see limitations in Medicare and Medicaid payments.

What Does Obamacare Mean for Nurses?
Nurses are also likely to see an impact from Obamacare. The American Nursing
Association, and many of its members, believe that access to high-quality
healthcare is something that more people need. From that standpoint, nurses
will now see more patients with coverage. That could mean the following:
 More patients seen on a daily basis. That's simply because there are more
people who have access to healthcare.
 More preventive care appointments, which are often nurse-led. Nurses are
likely to see a push towards preventive care services in many practices.
 More paperwork in terms of meeting the law's requirements for reporting

 Possible increased demand for traveling nurses, who move from place to
place to meet needs in response to shortages. This may occur as hospitals
work to fill openings in order to meet preventive care requirements and
demands.
 With Medicare and Medicaid remaining as large components of
Obamacare, many RNs will see a push toward increasing education to
meet demands within the industry. It may even be likely that the
American Nursing Association will increase grant opportunities to push
nurses towards getting the required education.

How Does Obamacare Affect Hospitals?
To further explore this topic, it is important to look at the effect of the new law
on hospitals. One key way this law impacts hospitals is by withholding
Medicare payments from hospitals that see too many patients returning within
30 days of discharge for specific ailments, such as pneumonia and heart attacks.
Hospitals must ensure that patients are healthy enough to go home, and must
also improve post-surgical treatment and services to decrease the likelihood that
patients will need to return. This may mean that hospitals will need to assign
outpatient nurses to ensure patients are following doctor's orders even after
discharge.
There's no doubt that quality of care can increase in hospital settings when
there's a risk of losing funding. In 2015, reimbursement rates will be cut by a
full percent to hospitals that have high infection rates.
Numerous changes will occur behind the scenes, including new training and
potentially new mergers to minimize costs and streamline efficiency. Hospitals
may also see a decrease in the number of patients who arrive to receive
treatment without any method of payment. That's because more people will
have coverage.

Obamacare Affects Patients and Doctors at All Levels
The requirement to obtain healthcare makes a big difference in the way people
live their lives. While it is an added expense, it may also mean better levels of
care from doctors and hospitals. At the same time, it means significant changes
for doctors, some of which could be too costly for them to keep private

practices open. Though salaries may be impacted, some doctors are happy to see
plans in place that ensure patients are getting the medical care they need for
early diagnosis and long-term treatment.

How Obamacare Affects Employers And How They're
Responding
Do employers have to do anything different under the Affordable
Care Act?
Not right away. The only thing required of employers at the start is that they
notify workers that the new health insurance exchanges have opened. You may
have received a letter from your employer to this effect — you probably don't
need to do anything.
Starting in 2015, large employers with 50 or more workers have a responsibility
— but no mandate — to offer employees health coverage. If they don't, they
may face fines, but only if their workers go to health insurance exchanges and
have earnings low enough to qualify for federal subsidies. Stores and restaurants
— less likely to offer health insurance in the past — may be most affected. The
coverage rule doesn't affect workers who put in less than 30 hours a week.
There are no responsibilities for small employers with fewer than 50 workers. If
they want to buy coverage for their employees, the insurance exchanges
represent a new option for them in terms of where to shop. Certain employers
with fewer than 25 workers are eligible for federal tax credits. To qualify, the
company has to cover at least half of the premium for all of its employees, and
also have average wages of less than $50,000.

Will my employer cut back on my insurance coverage?
A number of employers have been overhauling the health benefits they offer
employees, citing rising costs.
There are two themes to what they are doing. In trying to control their own
spending, employers often are shifting health costs to employees. So the
average annual deductible for an individual — what consumers pay before

insurance kicks in — nearly doubled in the past seven years, from $584 in 2006
to $1,135 this year, according to the Kaiser Family Foundation.
But employers aren't just making workers pay more. They're trying to make
them think more about health-related expenses and behavior.
Companies such as grocer Kroger Co. pay only a fixed amount for particular
drugs or procedures, giving patients incentive to shop around for the best price.
IBM started giving rebates to workers who adopt healthy lifestyles. Penalizing
smokers with surcharges is one of the few discriminatory measures the health
act allows.

What about part-time workers?
Nothing in the Affordable Care Act says that employers have to cover part-time
workers. The law defines part time as someone who works less than 30 hours a
week.
Some employers that have offered part-time workers minimal coverage, such as
Trader Joe's and Home Depot, have dropped it on the grounds that those
workers can now find coverage through the insurance exchanges. Most workers
in this situation will be pleased with the outcome. They'll likelyfind better
coverage than what they had for less money. Although depending on the
situation, some people may see their premiums go up.

Are employers reducing their workforce as a result of the
Affordable Care Act?
There have been reports of employers holding back on hiring in order to stay
under the 50-employee threshold that triggers health insurance responsibilities.
There also have been reports of employers cutting workers' hours to below 30
per week so that they don't count as full-time. While there is anecdotal evidence
of both things happening, there's no evidence that those cases have added up to
a broader drag on the economy as a whole.

Will my company stop offering coverage to my spouse and
dependents?

Some companies, including UPS, have decided to stop covering working
spouses if they have access to coverage at their own jobs. The health law does
not require employers to cover spouses, but surveys show that only a minority
of companies have implemented a "spousal exclusion."
However, employers increasingly offer incentives to get spouses off their plans.
They may charge workers extra if a covered spouse has access to other
insurance, or they may pay bonuses when spouses are not on the company
policy.

Will COBRA rates increase?
COBRA is a transitional arrangement that allows you to stay on a former
employer's health insurance for up to 18 months after you've stopped working
for them. It's expensive: You pay the entire premium — including any share the
employer had previously paid on your behalf — plus a 2 percent administrative
fee.
Whether your COBRA rate will go up depends entirely on what happens with
your former employer's health insurance plans. If their rates go up, so will
yours. You'll likely see a higher increase than your former co-workers, however.
That's because their premiums may be subsidized by the employer, whereas
yours are not.
Many people who might have used COBRA will find that buying insurance on
the exchanges is cheaper. But pay close attention to when the enrollment period
for the exchanges are.People who enroll in COBRA and later decide they want
to switch to an exchange plan generally won't be allowed to do so until the
exchange's next annual open enrollment period. An exception would be if they
exhaust their COBRA coverage.

Does ObamaCare Require American’s to Purchase Health
Insurance?

They
must
obtain
and
maintain minimum
essential
coverage throughout the year, get an exemption, or face a tax penalty for
each month you go without coverage. In the individual and family market
major medical coverage that counts as minimum essential coverage can only be
purchased during open enrollment. Open enrollment for 2015 is Nov 15, 2014
through Feb 15, 2015.
In most cases if you already have health insurance you like, you can keep it
(although some plans are being phased out by 2017, For many low to middle
income Americans, insurance is more affordable due to cost assistance and
Medicaid Expansion. However, those making above 400% of the federal
poverty line may find themselves paying more for coverage and may want to
see private health plan options out-side of the marketplace. Regardless of what
you pay we all enjoy the new benefits, rights, and protections offered by
Obamacare.

Open Enrollment Under the Affordable Care Act
Under the Affordable Care Act most private insurance must be obtained during
the marketplaces annual open enrollment period. Open enrollment periods
protect insurers from folks simply waiting until they get sick to be covered and
helps enforce the mandate and keep premium costs down. You won’t be able to
get most types of private coverage outside of open enrollment without
qualifying for a special enrollment period. Other insurance types like Medicaid
and CHIP (which is 365) have unique open enrollment periods.
To comply with the law for 2014 you needed to get coverage that started by
May 1st, 2014 to avoid the fee. Open enrollment for 2015 starts November 15th,
2014 and ends February 15th, 2015. You’ll need to get covered before then, and
maintain coverage to avoid the per month fee.
If you miss the annual open enrollment period, you may still have options.
Individuals may qualify for special enrollment period outside of open
enrollment if they experience certain qualifying life events. Learn what to do
if you missed the ObamaCare deadline.

ObamaCare Doesn’t Create Insurance
ObamaCare (The Affordable Care Act) doesn’t create private or public health
insurance, it expands and improves public health insurance options like
Medicaid and Medicaid. The ACA also creates a subsidized and regulated
marketplaces where Americans can buy private health insurance using group
buying power.
Although the expansion of Medicaid and cost assistance (both of which are
subsidized by taxpayers) have gotten some criticism for being “hand outs to
those who don’t want to work,” that criticism is mostly unfounded. The truth is,
most of the newly insured will be working poor families who couldn’t
previously afford health insurance and those with pre-existing conditions who
were previously “uninsurable” or priced out of insurance. Those who don’t want
to, or can’t work already have access to Medicaid in most cases. It’s myths and
half truths like these that inspired us to create this facts site.

ObamaCare Health Insurance Exchanges (Marketplaces)

Under the Affordable Care Act, every legal resident of the United States of
America will be able to shop for health insurance in their State’s online Health
Insurance Marketplace (sometimes known as a exchange). The “ObamaCare
Exchanges” are online marketplaces where Americans can shop for regulated
health insurance and low-to-middle income Americans can get cost assistance.
Open enrollment is the only time you can get covered and apply for cost
assistance without qualifying for a special enrollment period.
Using the marketplace any American can research every available policy and
choose the right one for them and their family. The cost of your health insurance
through the marketplace depends on your income, so only those making less
than 400% of the Federal poverty level will be able to use cost assistance to
obtain free or low cost health insurance. If you have access to affordable
employer based coverage you won’t be able to get cost assistance. If you are
eligible for Medicare, you can’t buy a private insurance policy and won’t use
the marketplace to get coverage.

Marketplace Health Plans
There are four types of “metal plans” (bronze, silver, gold, and platinum)
available on the marketplace as well as a catastrophic plan for those under 30
and those who had their plan canceled due to the ACA. You can also use the
marketplace to sign up for Medicaid and CHIP. Medicare and other health
insurance programs are signed up for separately. You can still buy private
insurance through a broker or direct from a provider. See how to buy health
insurance for more details on your options for obtaining coverage in 2015 or
check out our guide to sign up for health insurance to find out your sign up
options.

What Will ObamaCare Cost?
ObamaCare (the Affordable Care Act) contains new taxes including a fee for not
obtaining insurance, as well as tiered cost assistance based on income. For those
who get cost assistance their coverage will cost between 0%-9.5% of their
income for the cheapest plan. Folks without access to cost assistance may end
up paying more, in part due to ObamaCare’s new rights and protections, and in
part due to the ever rising costs of premiums.
The bottom line is that while the ACA aims to give more people access to
affordable, quality health insurance and it succeeds in many ways, but that
doesn’t mean everyone will pay less. In general the less you make, the less you
pay. Regardless of if you will pay more or less, the quality of health insurance
you receive has new, benefits, rights and protections making it a better quality
health health insurance. After all, what good is health insurance that drops you
when you get sick, drops you when you use too much, or denies you for being
sick in the first place?
As for our costs as a country and cost beyond health insurance, the Affordable
Care Act does address the growing cost of health care, but it’s main focus is on
reforming and expanding health insurance. Unless we as a nation address the
root causes of health care costs a meaningful way the costs and taxes associated
with healthcare will continue to put a burden on Americans, regardless of the
law..

ObamaCare Medicare Reforms
ObamaCare cuts $716 billion (gross) in Medicare and Medicare Advantage
related spending and reinvests it back into both Medicare and other aspects of
the Affordable Care Act.
The Affordable care Act does more than just make cuts to Medicare, it provides
a wide array of improvements for seniors. Some major reforms include closing
the Medicare Part D “donut hole” and providing better quality preventive
services to seniors.
ObamaCare Medicaid Expansion expands Medicaid to 15.9 million of our
nation’s poorest, including 9 million children by means of expanding CHIP
(Children’s Health Insurance Program). However, this aspect of healthcare
reform is in jeopardy in some states due to the states’ ability to opt out of
Medicaid expansion. Twenty-four States have already opted out of Medicaid
expansion leaving 5.7 million Americans without proper healthcare. Find out
more about ObamaCare Expanding Medicaid.

ObamaCare Repeal Attempt Changes the Law
The Republican Party has tried to repeal ObamaCare more than 50 times. Since
ObamaCare was upheld in the Supreme Court and Barack Obama was sworn
into office for a second term, the Affordable care Act has become “the law of
the land”, albeit with some major changes made in the Supreme Court ruling.
Some of the changes include states being able to opt out of expanding Medicaid
to it’s poorest and the ruling of the individual mandate’s “shared responsibility
fee” as a tax.
Since the NFIB lawsuit, additional lawsuits have changed other aspects of how
the law works and what the fate of the law could be moving forward.
States Opting Out of Medicaid Expansion
Under Medicaid expansion states had the opportunity to expand Medicaid
eligibility to everyone making less than 138% of the federal poverty level. In
states that did not expand, 5.7 million will remain uncovered due to narrow
eligibility guidelines used by those states.
States Opting Out of Creating Marketplaces

When the law was written it was assumed that all states would create their own
Health Insurance Marketplaces. However, many states deferred running their
own marketplace to the Federal Government. The Federal Government’s
marketplace became the official marketplace
While the law allowed for states to have the Federal Government run their site,
specific wording of the law that says The Affordable Care Act authorizes federal
subsidies for health coverage obtained on an “Exchange established by the State
under section 1311.” This has led to several court cases that charge that
subsidies should be illegal in states that deferred setting up their marketplaces to
the Federal Government.

Is ObamaCare Socialized Healthcare / Health Insurance?
The idea that ObamaCare is socialized healthcare or socialized health insurance
is a myth. Socialized healthcare implies that all health care workers work for the
federal government and all the hospitals and clinics are owned by the
government (public healthcare delivery), while socialized health insurance
implies that health insurance is run by the government (public healthcare
funding). The American healthcare and health insurance system, both before
and after the Affordable Care Act,arebest described as a uniquely American,
mixed-market approach to healthcare and health insurance, which use
combinations of public and private funding and delivery methods.

What Else Does ObamaCare’s Health Care Reform Cover?
ObamaCare aims to provide quality healthcare for more Americans at more
affordable rates. Health care reform under the Affordable Care Act is the most
significant overhaul of the health care industry in decades, covering every
aspect of healthcare including mental heath, care for seniors, child health,
woman’s health and care for our nations poorest. ObamaCare also provides drug
coverage, free preventive care, check ups for children and countless other
unprecedented reforms to the American health care system. ObamaCare may
not be perfect, but it does a lot to expand the average Americans health care
rights.

Obamacare: Seven Major Provisions And How They Affect You:
Obamacare, or the PPACA if you prefer, will drastically change major aspects
of “the finest healthcare system in the world.” Without question, our system had
its problems. Specifically, the cost of health insurance and medical care was
indeed rising too fast. Even so, have we taken a chainsaw to fix an issue which
could have been remedied with a scalpel and a few sutures? After all, on
average, our health care system contained far more strengths than weaknesses.
Judging by the number of patients that have come from foreign lands to receive
medical care in the U.S., the world whole-heartedly agrees. However, this is all
changing. How will Americans receive their health care in the future? What
changes can we expect?

Health Care Delivery Systems

In the future, Americans will acquire health insurance through one of four
venues. They are:
1. Government provided (i.e.; Medicaid, Medicare, etc.);
2. Employer provided;
3. Exchanges; and
4. Other.
Today, most people obtain their health insurance through their employer. A large
number are also insured through the government. Most of those who remain
will go through an Exchange, especially since this is the only way to obtain a
premium subsidy.

Overview of Obamacare Provisions

The PPACA contains a number of requirements to which insurers and
individuals must adhere. Here is a list of the major changes under
Obamacare.
Guaranteed Issue: Health insurers will no longer be able to deny coverage
based on current or prior health. Depending on enrollment, premiums are likely
to trend higher. This could also have a negative impact on the quality of the
“risk pool” as those previously unable to obtain insurance will now be eligible
for coverage.

Minimum Standards: Each policy must now meet certain minimum coverage
standards called essential health benefits (EHB). In addition, children can
remain on their parents’ health coverage until age 26. This may cause premiums
to rise if the new minimum standards are higher than existing coverage.

Individual Mandate: Unless you qualify for an exemption, you are now
required to purchase health insurance or pay a non-compliance penalty. This
could cause premiums to fall because younger individuals must purchase
coverage and this group is generally in better health. Therefore, younger
individuals will be supporting those who are older. However, I suspect this will
be a nightmare to enforce as many young people will simply choose not to
participate. After all, when you’re young, health insurance is a low priority.

Health Insurance Exchanges: If you do not have insurance through your
employer or the government, you will either purchase it through your state’s
Exchange (if available), the Federal Exchange, or through what I call “Other.”
This could cause premiums to rise as it will add an additional layer of
bureaucracy and expense. Also, because government has no profit motive, there
is less incentive to operate with the same efficiency as a private sector company.

Low Income Subsidies: Individuals and families with an income less than
400% of the federal poverty level who purchase health insurance through an
Exchange will be eligible for a subsidy from the government. The federal
poverty level is based on the number of family members and state of residence.
See TABLE A for details. This will put tremendous pressure on the federal

budget and create an argument for higher taxes. As has occurred numerous
times in the past, actual costs will almost certainly exceed projections.
Moreover, anytime the government subsidizes a program, its cost tends to
increase. Just look at our university system and the staggering cost of a fouryear program.

Medicaid Expansion: Medicaid is a state-administered program created in
1965 to provide healthcare services to the poor. Moreover, this program has
been a major budgetary item for state governments for many years. To help, the
federal government contributes a percentage of each state’s Medicaid budget, as
long as the state abides by federal guidelines. The federal reimbursement
percentage varies from state to state, but averages about 57 percent.
One of the major provisions of Obamacare was an increase in the Medicaid
income threshold which is used to determine if an individual or family qualifies
for the program. Any expansion in Medicaid, even if supplemented by the
federal government, will increase expenses for the state. This issue also ended
up in the Supreme Court where a fragmented and diverse set of opinions
ensued. However, the court ruled that a state may “opt out” of the expansion
without jeopardizing its existing federal Medicaid contributions. Many states
did exactly that while others are allowing the expansion. One source reported
that, as of October 22, 2013, 15 states have opted out, 7 are leaning that way, 21

are participating, 3 are leaning in that direction, and the rest are considering an
alternative model. In any event, millions of additional people will now qualify
for, and enroll in, Medicaid. TABLE B provides the number of individuals who
have received a benefit from Medicaid and the total dollar amount the program
paid from 2000 through 2009. This will most certainly put upward pressure on
health care costs and premiums. It will also be amplified by any operational
inefficiencies which may persist.
If your state did not opt out, you may qualify for Medicaid if you earn up to
133% of the federal poverty level (See TABLE A). Obamacare also provides a
5% “income disregard” which effectively increases the qualifying threshold to
138%.

Medicare payment Reforms: Currently, medical payments under Medicare are
paid on a “fee-for-service” basis. With Obamacare, payments will be “bundled.”
For example, if you had a knee replacement, in the past, you would receive a
bill from the medical facility, the surgeon, the anesthesiologist, etc. Under a

bundled system, a single payment will be made to a hospital and a physician
group for a specific procedure.
I believe this approach has many potential problems. First, someone must
decide how much will be paid for each procedure. Moreover, adjustments will
need to be made for complications and the degree of complication will also
vary. Then, allowances must be made for geographic differences. In short, will a
knee replacement cost the same in Quitman, Mississippi and Los Angeles,
California?
This could push premiums higher depending on the amount of payment allowed
for various procedures and the physicians willingness to accept it. If the
allowable payments are perceived as too low, it could cause medical providers
to refuse Medicare patients. If enough practitioners did this, the government
could hire its own doctors and take control of this segment of health care or they
could increase the allowable fees to make it attractive for practitioners to
continue accepting Medicare patients. With the complexity of the PPACA and
the aging U.S. population, this could become a very significant issue.

Obamacare’s Many Negative Side-Effects Should Surprise No
One
Even left liberals are coming to realize that Obamacare is fatally flawed.
Perhaps this is because fewer people will be insured at the end of the year, under
Obamacare, than at the beginning of the year as insurers are forced to drop
coverage. Stories of such cancellations to cancer-stricken children certainly
don’t help matters. For a program whose expressed purpose is to bring
insurance to more people, this irony seems even too much for the
interventionists to stomach.
Obamacare’s negative effects, however, are simply a microcosm of government
policy in general. Virtually all well-intended (assuming they are in fact wellintended) government policies bring negative unintended consequences that hurt
the very people they intend to serve. The prevalence of this paradox, called
iatrogenics (originally used in the medical context to refer to doctors’ actions
that hurt patients), should give pause to those who favor government
intervention to solve societal problems.
Take rent control policies, for example, intended to make housing more
accessible to those with lower incomes. In reality these policies shrink the
amount of available housing because potential landlords have less incentive to

rent out, and developers have less incentive to build new, units. As a result, less
housing is available for those with lower incomes. Just look at the apartment
shortage in New York or San Francisco, the two cities with the most stringent
rent-control policies, for proof.
This process of iatrogenics also exists in financial regulation. Polemicist Nassim
Taleb has illustrated how increased financial regulation intended to prevent
another financial crisis has actually made one more likely. Regulations entrust
the fate of the financial system to a handful of big banks because they are the
only ones who can afford to comply with them. This consolidation of power
among the big banks makes the financial system riskier because if one of these
few banks fails the damage will be much greater to the economy than from the
failure of one small bank among many. “These attempts to eliminate the
business cycle,” says Taleb, “lead to the mother of all fragilities.”
In terms of protecting society’s most economically disadvantaged, sociologist
Charles Murray chronicles, most recently in his bestseller Coming Apart, how
the federal government’s war on poverty paradoxically hurts the poor. He
explains that though welfare benefits are well intentioned, what they in effect do
is pay people to stay poor, hurting the very people they intend to help. These
misaligned incentives are a leading reason why $15 trillion in welfare spending
over the past 50 years has perversely resulted in a 50-year-high poverty rate of
15.1 percent.
Those currently advocating for a raise of the minimum wage should first
examine its iatrogenic history of bringing about negative unintended
consequences to the very low wage people it intends to help. Minimum wage
increases actually hurt low wage earners because business owners lay off staff
and cut back on hours to try to recoup their losses from such mandated wage
increases. This leaves those with a tenuous grasp on the labor market in an even
more precarious position. “Unfortunately, the real minimum wage is always
zero, regardless of the laws,” says economist Thomas Sowell, “and that is the
wage that many workers receive in the wake of the creation or escalation of a
government-mandated minimum wage, because they either lose their jobs or fail
to find jobs.”
Of course it’s not only left liberal policies that generate negative unintended
consequences that hurt the very people they’re intended to help, but also
conservative ones like the war on drugs and the war on terror.
The war on drugs intends to help drug-blighted communities by enacting and
enforcing strict penalties on drug use. What it in effect does is hurt these
communities by making criminals out of a significant portion of its inhabitants.
Drug users now make up nearly 25 percent of federal and state prison inmates,
many of whom go in for simple possessions and come out hardened criminals

wreaking untold damage on their communities. Even those who do not run afoul
with the law again face a lifetime of job and social struggles with a criminal
record attached to their name.
The same iatrogenic story exists in the war on terror, which intends to keep us
safe by waging a multipronged offensive against potential terrorists and the
geographies they may inhabit. Unfortunately, as former CIA intelligence officer
Michael Scheuer has illustrated, some of these prongs, such as aggressive drone
warfare and support for apostate regimes, actually fan the flames of US hatred
making us less safe. “It’s American policy that enrages al-Qaeda,” says Scheuer,
“not American culture and society.”
Government intervention, no matter what its form or intention, causes
iatrogenics — unintended negative consequences that hurt the very people
they’re intended to help. Nowhere is this better exemplified than with
Obamacare, a policy intended to bring insurance to all that has in effect taken it
away from many. Perhaps the growing coalition of people recognizing this
paradox will take this revelation and apply it to other policy arenas as well. For
the affected classes, we can only hope.

Obamacare Is Not a Revolution, It Is Mere Evolution
The Patient Protection and Affordable Care Act focused the attention of
Americans on government regulation as few issues have. However, they should
have paid attention decades earlier because states have been eating away like
termites at freedom in the healthcare insurance market for decades. The PPACA
adds little to existing state regulations. States began dictating to insurance
companies what to cover, whom to cover, when to cover them and how much
they could charge in the 1950s. Massachusetts, home of Romneycare, the
template for Obamacare, enacted the first state mandate in 1956 requiring
insurers to cover mentally and physically handicapped children.1
States have mandated coverage in four areas: benefits, providers, populations,
and rates. Benefit mandates decree types of care, such as mammograms, wellchild care, drug and alcohol abuse treatment, but also acupuncture and wigs for
cancer patients. Provider mandates ordain payments to healthcare providers
such as chiropractors, podiatrists, social workers and massage therapists.
Population mandates increase the number of people covered under a policy,
such as extending coverage to non-custodial children and grand children. Rate
mandates prevent insurance companies from charging premiums that reflect
risk, in effect using low risk policy holders to subsidize high risk members.
Through the 1960s, state legislatures focused on commanding insurance
companies to cover more people. In the1970s, states began to require that
insurance policies cover non-physician practitioners, such as psychologists,
podiatrists, and dentists. States expanded coverage to high-risk individuals who
had been turned down for coverage by one or more insurers in the 1980s.
The decade of the 1990s ignited the war between managed care plans and their
subscribers. State legislators entered the war on the subscriber’s side, launching
a fusillade of new mandates dealing with the types of coverage offered. Among
the many laws were minimums for hospital lengths-of-stay and coverage for
hospital care following procedures such as normal childbirth, cesarean delivery,
and mastectomy.
In addition, states enacted any-willing-provider (AWP) laws, forcing managed
care firms to admit any provider willing to abide by the terms of the network
contract. Freedom-of-choice (FOC) laws required that managed care plans
allow subscribers to visit any licensed provider they desired as long as the
subscriber paid a larger out-of-pocket fee when they used a provider from
outside the network. Direct access mandates allowed subscribers to visit
specialists, such as OB/GYNs, dermatologists, ophthalmologists, psychiatrists,
chiropractors, etc., without first getting approval of the subscriber’s primary

care physician (PCP). Managed care plans had tried to limit the rapid growth in
medical care expenses by requiring the approval of a PCP before subscribers
visited costly specialists.
The new millennium continued the onslaught of state regulations aimed at
healthcare insurers. Between 1950 and 2000, states had enacted an average of
22 laws per year, with the average for the last decade rising to 57 per year. The
first 11 years of the twenty-first century saw the average climb to 61 mandates
per year.2 The chart below depicts the growth in state mandated laws over the
past six decades. As of 2011, the total number of laws controlling insurance
coverage amounted to 2,262 according to the Council for Affordable Healthcare
Insurance.
The most popular new mandates cover autism, diabetes, oral and infusion
chemotherapy, diabetes and screenings. As the number of news diagnoses of
autism has exploded, so have the mandates. “To date, 29 states have passed
autism mandates and the amount of proposed legislation grows each year.
Advances in diagnosis (including a new rapid test to screen for autism) and
treatment, along with a well organized national advocacy movement, guarantees
autism mandates will remain high on legislative priority lists”4 according the
CAHI.
Oral and infusion chemotherapy is a regimen in cancer treatment that can be
administered at home instead of a clinic or hospital. At least 15 states have
passed such mandates. Diabetes is growing rapidly in the US as a result of the
obesity epidemic. A 2009 University of Chicago study concluded that the
number of diabetics will double in the following 25 years. As a result, 41 states
have mandated coverage of diabetes.5
Mandates to pay for screening have increased in part because “most legislators
and policymakers believe all preventive care saves lives and money. Recent
studies reported in the Journal of the American Medical Association and
elsewhere, however, are casting doubt on this idea. A number of screening tests
have been shown to produce ‘false positive’ results, leading to expensive and
unnecessary treatments.”6
The least-discussed mandates are those applying to what companies can charge
for premiums. Rate mandates are a form of state price controls. Before one can
appreciate the impact of price controls, one needs to understand how normal
insurance works, such as car or house insurance, and prices premiums.
Insurance companies hire actuaries to establish rates using probability theory,
statistics and risk theory. Greater risks result in higher premiums. Things that
affect risk in healthcare include geography, demographics (age and gender), and
health status.

Consumers grasp these concepts easily with home and car insurance. For
example, a house located in a flood plain will cause the owner to pay higher
insurance premiums. Home owners in the southern plains states pay higher
premiums than those on the west coast because of the frequency of hail in
thunderstorms on the plains. Car insurance for teenage boys costs much more
than the same coverage for girls or for older married men. These are examples
of higher risks that cause higher premiums. The same should be true of
healthcare insurance, but it is not.
Some states impose rate bands on insurance premiums. Rate bands set upper
and lower limits on how much premiums can vary from the average due to risk
factors such as gender, age, or health status. Many states allow the insurer to
vary premiums by no more than 50 percent from the average. For example, if
the average premium is $1,200 per month, the company can charge no more
than $1,800 and no less than $600, which produces a 3:1 ratio of highest to
lowest premiums. Other states allow no more than a 2:1 ratio. Such rate bands
force young, healthy subscribers to subsidize the premiums of older, sicker
ones.
The managed care provider I work for had a hemophiliac as a subscriber for
many years who regularly cost the company over $1 million per year in medical
bills. Oklahoma enforces rate bands on premiums, so the company could not
charge that member any more than other subscribers whose medical expenses
totaled less than 10 percent of his. Fortunately for our company, his employer
chose another health care insurer. So far we have looked at state mandates only,
but the federal government has not remained unconcerned about health care
insurance. The federal government issued the Pregnancy Discrimination Act in
1978, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),
the 1996 Health Insurance Portability and Accountability Act (HIPAA), the
1996 Mental Health Parity Act, and the 1996 Newborns and Mothers Health
Protection Act (NMHPA).
The Pregnancy Discrimination Act requires health plans to provide benefits for
prenatal and maternity services comparable to the coverage for other conditions.
COBRA requires companies with 20 or more workers to continue providing the
group insurance to former employees who have been separated, though the
former employee and not the company pays the premiums. The premium cannot
exceed 102 percent of the group premium.
HIPAA limits preexisting-condition clauses to one year before enrollment. In
addition, the insurer must waive such clauses for subscribers who change plans
if they have satisfied the waiting period for coverage under the previous plan.
Plans cannot consider pregnancy a preexisting condition nor subject newborns
or adopted children who are insured within 30 days of birth or adoption to the

plan’s preexisting-condition clause. Under the Mental Health Parity Act, plans
that include coverage for mental health care must provide the same annual and
lifetime reimbursement ceilings for such care that they offer for other nonmental health related ailments.
Unintended Consequences
In a 2007 review of the literature about the effects of state mandates on
insurance premiums, the authors concluded “Despite exhaustive research, little
compelling evidence exists that state health insurance mandates do, in fact, have
a significant impact on these outcomes.”7 Is it really possible such massive state
interventions in the insurance market, most of which create higher demand,
have no impact on prices?
CAHI says it just ain’t so: “Health insurance actuaries have warned that
virtually all mandates increase the cost of coverage by increasing utilization
over time (referred to as “frequency of use”). Why is this so? Mandates require
insurers to pay for care that consumers previously funded out of their own
pockets, if they purchased it at all. Changing the dynamics of payment creates
more frequent use of the service and a resultant increase in premium costs to all
health insurance beneficiaries.”8
CAHI estimates that mandates can boost premiums from 10 percent to 50
percent depending on the state, number of mandates, and the type of policies.
Jensen and Morrissy found in 1990 that some benefits boost premiums
significantly. Adding chemical dependency treatment lifted premiums 9 percent
on average. Psychiatric hospital stays raised premiums 13 percent. Visits to
psychologist increased them by 12 percent and routine dental services by 15
percent.9
James Bailey, an economist at Temple University, discovered results similar to
those of CAHI: “When a mandate is passed, more medical spending is
channeled through insurers, rather than being paid directly out-of-pocket by
consumers. This partly explains the long-term shift away from out-of-pocket
spending in the US health care market. ... As more medical spending is done
using insurance, health insurance costs and premiums will rise.”10 The graph in
figure 2 below depicting the source of healthcare spending
in 2010 were $4,952.
Why is it so difficult to determine the price effect of state mandates on
insurance premiums? The answer is that all people do not respond in the same
way to price changes. Insurance companies try not to raise premiums if possible
because in most states they compete for customers on the basis of premium
prices. Most groups offer more than one insurance provider to their employees.

Healthier employees will switch to cheaper plans, so insurance companies may
choose to increase out-of-pocket expenses instead ofIf an insurer raises
premiums, companies paying the premiums for employees may opt for reduced
benefits, switch insurers, have employees pay a larger share of the premium, or
abandon company-paid insurance completely. The cost of mandates may be
masked by the rising number of uninsured. Finally, companies may choose to
become self-insured, in which case they are exempt from state mandates but
must follow federal mandates. Self-insured plans cover over 57 percent of
privately insured people.
Whatever the cause, insurance premiums have risen fast according to Milliman,
an independent actuarial and consulting firm. The Milliman Index estimated that
premiums for a family of four have doubled in less than nine years, from $9,235
per year in 2002 to $19,393 in 2011.13 raising premiums.

Obamacare: Quintessential Socialism
The overriding characteristic of President Obama's National Socialist healthcare
is forced equality of consumption, a major step in the direction of egalitarian
distribution of income. Emphasis is upon the word forced.
As we see with the widespread town hall protests against the President's
proposed National Socialist healthcare proposals, people do not willingly
surrender the fruits of many years' labor to the government in the name of an
undefined abstraction called the common good. Particularly is this true when it
is liberal-progressive bureaucrats who decide arbitrarily what constitutes the
common good.
In a Wall Street Journal op-ed essay, Martin Feldstein, Harvard economics
professor and former chairman of President Reagan's Council of Economic
Advisors, sums up Obamacare: it's all about the raw power to decide who gets
what treatment, while cramming everyone into identical little boxes in order to
eliminate any efforts in the direction of individuality. And the bureaucratic
mechanism for eliminating individuality is rationing medical care.
Despite the repeated lies by the President and his spokesmen, as Professor
Feldstein writes, the National Socialist healthcare bill passed by House Speaker
Nancy Pelosi clearly contemplates rationing.
Many supporters of Obamacare argue that healthcare already is rationed by
money availability, because Medicare, Medicaid, and insurance companies will
pay only certain amounts for care and will refuse to pay for some specialized
treatments or prescription drugs. This ignores the obvious fact that individuals
are free to make choices to pay for such care themselves and that it was
individuals who selected the insurance payment programs they have.
Under Obamacare, all private insurance would eventually be compelled to offer
exactly the same scope of insurance as the so-called public option. Everybody
will be compelled to have the same coverage program, whether he is old, young,
in poor health, or in good health.
The argument that medical care already is rationed also reflects a deep-rooted
aspect of the liberal-progressive-socialist paradigm: the idea that individuals
possessing more money than others is an inherently unjust social condition.
Michael Walzer's analysis of that paradigm is typical. Professsor Walzer, one of
liberal-progressive-socialism's most prominent theorists, is co-editor of Dissent,
a leading socialist journal.

Walzer contends that possession of money amounts to power and that such
power is both unjust and unjustly used. It enables the rich to purchase every sort
of social good. Why should these goods be distributed to people who have a
talent for making money? This, he says, is morally implausible and
unsatisfying.
Nor would it be better if we gave money to people on the basis of their
intelligence, strength, or moral rectitude. There is no single talent or
combination of talents that entitles a man to every available social good.
In the socialists' view, all that should count is need. If people need certain things
(leaving aside how that need is determined), they should simply be given them,
without regard to their ability to pay. This is what is meant, in Professor
Walzer's sense, by social justice. Whenever equality in this sense does not exist,
we have a kind of tyranny in which the strong, the well-born, and the wealthy
get social goods in amounts that have little to do with their personal qualities or
needs.
With respect to medical care, Walzer believes that it should be distributed only
to those who are sick, without regard to wealth, intelligence, or righteousness.
But in America today, it is closely follows the income curve. "From each
according to his abilities, to each according to his needs," would, however, be a
fine slogan for medical care, he says. Taxes paid by all of us should pay doctors
and other medical care providers. This, says Professor Walzer, necessitates a
national health service of a sort to which Obamacare inevitably leads.
It isn't that every man should get what he deserves, as in the old definition of
justice. The new standard is egalitarian, that is, everyone should have free and
equal access to all the goods and services produced by our economy.
Liberal-progressive-socialists' goal is to restructure our political system to make
a society of equals that is worth having. The starting point must be to end the
tyranny of personal wealth.
A good doctor deserves society's praise, according to Professor Walzer, but that
is no reason to pay him any more than any other worker. Why should a
steelworker have to work much longer than a doctor for the money to have a
home or an automobile? There are rewards intrinsic to the doctor's job, like the
pleasure of using his specialized knowledge for the common good. That ought
to be enough. There is no meritocratic defense for differences in pay.
As liberals like Professor Walzer see things, the rewards of the good life are
social goods that the rich have habitually taken for themselves, without regard
to any personal merit. They are merely the rewards that the upper classes
throughout history have been able to seize and hold for themselves. Affirmativeaction quotas are a way of redistributing these rewards by redistributing the

social places that conventionally get the rewards. National Socialist healthcare
is another.

Nearly 200K Coloradans face Obamacare cancellations by 2016
Nearly 200,000 insured Coloradans will lose their health-care plans next year
under the state’s embattled Obamacare exchange, Connect for Health Colorado.
State insurance commissioner Marguerite Salazar touched off an outcry Friday
by confirming to news outlets that health-care policies covering 190,000 people
will be dropped in 2016 because they fail to comply with the Affordable Care
Act.
Colorado Senate Majority Leader Bill Cadman called the action “a huge blow to
another 190,000 Coloradans who will be forced out of their existing healthcare
plans.”
A year ago, President Obama extended the deadline on policies that failed to
meet Obamacare’s heightened coverage requirements, allowing policyholders to
renew their old coverage through 2016, but Ms. Salazar decided that a one-year
extension was enough, said her spokesman, Vincent Plymell.
“She gave people the extra year last year to continue these plans and just felt
that it was time now. The ACA passed in 2010 and it’s time to move people to
better coverage,” Mr. Plymell told Health News Colorado.
Those holding non-compliant health-care policies will have 90 days’ notice to
switch plans, he said, but Republicans were nonetheless furious to learn of the
cancellations.
Sen. Cory Gardner, Colorado Republican, urged state officials to reconsider and
allow the non-compliant policies to stay in effect for another year, pointing out
that “Coloradans were promised by supporters of this healthcare law that if they
liked their plans, they could keep their plans.”
“I am utterly appalled by this announcement. After all of the glitches, the
increased costs and premiums, and the plan cancellations that Coloradans have
already endured, the idea that the Division of Insurance would choose to cancel
the healthcare plans of hundreds of thousands more people is unconscionable,”
Mr. Gardner said in a statement.

More than 340,000 Coloradans have seen their policies cancelled since the
glitch-ridden Obamacare rollout in 2013. The cancellations dogged Democrats
in the 2014 election, contributing to the defeat of former Democratic Sen. Mark
Udall by Mr. Gardner.
Democratic Gov. John Hickenlooper, who won reelection in November, was
consulted on the decision, Ms. Salazar told 9News in Denver.
The Democrat-led state House gave preliminary approval Friday to a bill for a
comprehensive audit of Connect for Health Colorado. The Republicancontrolled state Senate has already approved the bill, which follows a scathing
limited audit released in December that faulted the exchange for sloppy
financial controls and oversight.
Rep. Mike Coffman, Colorado Republican, said he has a personal stake in the
issue: He signed up for health insurance on the state exchange and knows
“firsthand how terrible the Obamacare coverage is.”
“President Obama lied to the American people when he said ‘if you like your
plan you can keep your plan’ and now Colorado families are being forced to
bear the burden of that lie,” Mr. Coffman told 9News.

Obamacare is not universal health care.

Mary is single, in her late 50s, widowed and earning about $2,000 a month
cleaning bathrooms downtown. She's had no health insurance for the last
decade, but she's received medical care when she needed it at free clinics and
emergency rooms.
But now it's the era of Obamacare, and Mary hears that she has to buy health
insurance. We check her options on Maryland Health Connection, the state's
online health insurance exchange:
The cheapest "bronze plan" is only $2.20 per month, which will avoid a yearend fine for being uninsured, but it pays for little up until the $6,000 deductible.
The "silver plans" cost $130 to $360 per month with a $900 annual deductible,
but for those she'd have to choose between a health savings account, a limited

HMO provider network, a 40 percent or a $40 co-pay, and many other confusing
options.
None of it sounds like straightforward "affordable care" to her.
This isn't a story about error messages or frozen screens. Website crashes make
news; they don't make history. This is about the real implications of Obamacare,
about which ideas work in real life and which just sound good on paper.
Mary was just one of dozens of low-income Baltimoreans I met as a health
insurance enrollment volunteer in a Baltimore free clinic over the past six
months, but she shares the experience of thousands of Marylanders this season.
Once the website glitches subsided, the reality set in that the government was
telling uninsured people to spend a significant portion of their incomes on
health insurance. I have seen how many low-income Marylanders will remain
uninsured because of the cost and complexity of buying insurance.
If we really want universal health care, we need a public system that actually
includes all people, such as extending Medicare to all Americans. Obamacare's
individual mandate to buy health insurance does not reach everyone because
many uninsured individuals will not "buy-in" to an expensive and overly
complex insurance system.
Unlike some critics, I do not think the Affordable Care Act (a.k.a. Obamacare)
got everything wrong: It has made health insurance for individuals cheaper and
better. Obamacare expands Medicaid to cover more low-income people, creates
tax credits to make insurance cheaper for individuals, makes it illegal for
insurance companies to deny coverage based on preexisting conditions and
stops insurers from rescinding coverage when beneficiaries get sick.
But while Obamacare patches some of the gaping holes in the health insurance
market, it also fails to create access for many of the people who never budgeted
for insurance before. The bottom line is that Obamacare will insure millions, but
it will also leave tens of millions of Americans still uninsured.
The only way to reach "universal coverage" would be for all Americans to be
enrolled in basic public health insurance. This sort of "single-payer system"
already exists for Americans over 65 (i.e. Medicare). While many politicians
criticize single-payer systems, the millions of seniors who staunchly defend
their Medicare are living proof that universal public coverage is worthwhile.
True universal coverage would protect our nation's most vulnerable from
medical bankruptcy, it would save tremendously on administrative costs

currently siphoned off by the insurance industry, and it would vastly simplify
insurance in this country.
Plans are in motion to create a universal public health insurance system for
Vermonters of all ages, but the hodgepodge of government programs and private
insurers in Maryland continues to leave some of our neediest without a reliable
source of care.
In Washington, my very own U.S. Rep. Elijah Cummings co-sponsored the
Expanded & Improved Medicare for All Act in 2013, which tried to create this
kind of comprehensive system to insure every American, but he needs more
allies in Congress to turn this bill into law. On a local level, "Healthcare is a
Human Right — Maryland" is a grass roots alliance of physicians, labor groups,
and other Marylanders working to promote true universal health care in our
state, and they have several local organizing chapters that need your support.
After months of trying to help low-income Marylanders like Mary sign up, I'm
more convinced than ever that Obamacare will not reach many of the people
who need health insurance the most and that universal public coverage is the
only way we can provide real health care for all in Maryland.

Why ObamaCare Will Fail
Medicare, when proposed in 1965 was expected to cost $12 billion by 1990; it
cost $90 billion in that year — seven and a half times more than expected (or
more accurately, sold to the public). Medicaid was projected to cost $238
million per year. In its first year, the actual invoice came in at $1 billion — four
times greater than advertised. The hospitalization program was supposed to cost
$1 billion by 1987; instead the tab was $17 billion that year. The program has
been expanded to the point of being 37 times more costly (inflation-adjusted)
than originally sold.
Yet we are supposed to believe that we have an unfettered virgin market in
health care ruled by the law of the jungle, that insufficient regulation is causing
all of the problems and that the only rational solution is for the federal
government to take command of a sixth or more of the entire US economy; a
brand new, original idea.

Obamacare, being the most ambitious social entitlement program ever
conceived, much less attempted in the US, will only magnify and multiply the
failures of prior interventions.
The failures of Medicare, Medicaid and socialized health care systems around
the world are not accidents, rounding errors or bad luck of unanticipated
complications. Rather, they are the inevitable, predicable result of forceful
interference in the voluntary cooperation of free citizens. Obamacare will fail
for the same reason that the Soviet Union failed: command-and-control
economies cannot function rationally.
When President Ronald Reagan famously declared “Mr. Gorbachev, tear down
this wall” in 1987, few people believed that the concrete and razor-wire barrier
separating the communist East from the free West Berlin, Germany, would in
fact be demolished, liberating the citizen-inmates not only of the eastern sector
of Berlin, but of most of Eastern Europe and Russia itself just 2 years later. But
Reagan understood that a system conceived in the denial of individual liberty as
both the fundamental moral principle of civilization and as the only rational
basis for functioning economics, was doomed to collapse under its own weight.
He understood this in part because the downfall of the Soviet system had been
predicted a few years earlier … in 1922.
Ludwig von Mises, the Austrian (later American) economist, demonstrated that
socialism could never fulfill its promise no matter what variation was attempted
nor how wise and virtuous the men running it. In his book “Socialism” he
demonstrated logically that every wage and price control, every tariff, tax,
privilege, prejudice, manipulation and regulation that does not derive from
government’s legitimate need to prevent and punish murder, robbery, assault,
fraud, theft, rape, persecution and conspiracy distorts and destroys information
necessary for rational economic planning and action. If some collective entity
like the state owns or otherwise controls capital goods, land, natural resources,
factories, machinery, services, licensing etc. then there is no market for these
goods. There is no buying and selling, no bargaining and haggling, no
competition to compel lower prices, higher quality, better service and the
division of labor where each finds the role they are best suited to, and no supply
and demand.
If there is no market then there are no prices in the real sense of the word.
Prices constitute the indispensable information system for signaling the needs
and scarcities in an economy, and the cost of available alternatives. There are a
hundred different ways to build a building, and dozens of alternative materials
and techniques for each component. Which combination is the most

economical? Who knows? Without prices, there is no way of knowing. There is
no other metric that can adequately substitute for market prices. Economic
planning cannot function without these numbers.
That is why socialism fails every time it is tried: Economic calculation is
impossible under socialism.
And then there’s the bureaucracy, which von Mises also wrote about. With no
markets there is no competition, neither incentive nor reward for better
customer service or to provide a higher quality product at a lower price. The
entire economy becomes like a giant Post Office or Department of Motor
Vehicles, with self-serving, inner-directed bureaucracies with languages and
cultures of their own, foreign to the rest of us, with iron-clad privileges, job
security and pensions that do not vary with how well or poorly they serve
willing customers.
As applied to the health care market, those same principles apply. The more the
government commands and controls services, insurance, physicians and other
health professionals, drugs/pharmaceuticals, equipment like MRI machines,
devices like defibrillators etc. then the less flexible and innovative is the market
for these. There is: less buying and selling between parties commanding their
own resources on their own account and for their own benefit, less bargaining
and haggling (apart from government bullying from its position of monopoly
power, as in price controls shrinking Medicare payment schedules etc.), less
competition to compel lower prices, higher quality, better service and the
division of labor and less operation of supply and demand.
Furthermore, this system leads to: the abolition of profit and loss, whether for
providers, insurers or patients as legitimate regulators of behavior or scorecards
of success or failure; a reduced scope of the operation of prices, therefore a
breakdown of the indispensable economic information system of abundance,
scarcity and alternatives; reduced possibility to recover research and
development costs of breakthrough drugs (why bet billions when success makes
you a target?). Shortages, waiting lists and government-imposed rationing of
services, doctors, medicines etc. are the inevitable results.
With the market-based economic model suppressed, the only alternative is
bureaucratic management based on politically-derived values. The opinions,
concerns and desires of physicians, patients and families take a back seat to
functionaries who are completely removed from personal economic or
emotional involvement in the patient’s case. What matters to him is that he

faithfully executes the rules dictated to him by the dominant political party and
union bosses.
“Progressive” politicians love to feed on people’s resentment of “faceless”
bureaucrats at private insurance companies as evidence of the failure of the free
market. But when there is only one insurance company left, the government,
with the right to tax you rather than face its own bankruptcy no matter how
poorly it is run, people aren’t going to love that insurance company more than
the few nominally private ones we have now. Even if private insurance
companies survive ObamaCare, they will be taking their orders from the
bureaucracy and the czars, not from patients, families and physicians.
Socialized medicine is not a new idea. It has been tried again and again in
many advance countries yet has never achieved results to compare with the
relatively free United States. ObamaCare, the biggest such initiative of them all,
will be the biggest failure. The most passionate sincere supporters of the Patient
Protection and Affordable Care Act will be the most disappointed.

FUTURE DIFFICULTIES OF OBAMACARE
After January 2014, the PPACA will provide subsidies for individuals who do
not obtain coverage through an employer to obtain coverage through state-run
or federal exchanges. But the implementation of this plan is fraught with
difficulty because the PPACA did not eliminate the existing tax subsidies for
obtaining coverage through one’s place of employment. This combination has
the potential to upend existing coverage arrangements.
The analytical point is simple, although the required computations are
somewhat complex. For low-wage workers, the PPACA provides substantial
subsidies for coverage obtained through the government-regulated exchange. At
the same time, the tax code provides only modest subsidies for low-wage
workers obtaining coverage through their places of employment. For high-wage
workers, the subsidy pattern is reversed. After one factors in the penalty levied
on employers whose employees obtain coverage through the exchange, many
low-wage workers and their employers turn out to be jointly better off
financially if those workers obtain coverage through an exchange. At the other

end of the spectrum, high-wage workers and their employers are jointly better
off if coverage is supplied through the place of employment.
In practice, employers do not face an all-or-nothing choice, and the
opportunities for strategic behavior are numerous. If the employer can design a
benefit package that appeals to more low-risk/low-cost employees than highrisk/high-cost employees, members of the latter group will voluntarily drop out
of the employer-based plan. By migrating to the exchanges, they make
themselves and their employer better off, at the expense of taxpayers (and the
risk pool of those enrolled in the exchange) who have to pick up the slack.
These dynamics will place considerable pressure on existing coverage
arrangements. Some employers will do nothing. Others will drop coverage for
all employees. Many will experiment with fine-tuning the terms of coverage,
the boundaries of the firm, and its staffing. The only certain thing is that
existing arrangements will prove far from immutable—particularly when
employers and employees gain jointly from unbundling and rebundling of
coverage. Stated more concretely, the differential subsidies and incentives
created by the PPACA are likely to prove extremely destabilizing to the
continuation of employment-based coverage, which will, in turn, dramatically
increase the on-budget cost of the PPACA.
The Congressional Budget Office and Joint Committee on Taxation recently
tried to estimate the impact of the PPACA on employment-based coverage.[8]
Their baseline estimate is that “about 11 million people who would have had an
offer of employment-based coverage under prior law will not have an offer
under the [PP]ACA.”[9] Other plausible assumptions resulted in substantially
higher estimates.[10] So much for “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.”