The Affordable Care Act

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The Affordable Care Act AKA

“Obamacare”
A Research Summary Report By Tania Ballard
MG 460 Directed Study/Research in Management Instructor Dr. J. Wayne McCain

ATHENS STATE UNIVERSITY College of Business
April 20, 2011
NOTICE: This paper does not necessarily represent the opinion of the Administration, Faculty, or Staff of Athens State University.

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ABSTRACT The Affordable Care Act, AKA “Obamacare”

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

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The Affordable Care Act, AKA “Obamacare”

Do

the American people want the

future of health care to be in the hands of a few politicians; the same politicians that are making themselves exempt from their own policies? When it comes to our health care system, most of us agree that America is ready for a change. We need a system that delivers accessible, high quality care, but we can’t achieve this goal with government policies that attack the foundation of our current health care system which is employer-sponsored health insurance. The Obama administration and members of congress are pushing legislation to set up a government run health care system. This government-run system would operate in competition with private health insurance that is commonly provided by many employers to employees and their families. Employer sponsored health insurance is the backbone of our nation’s health care system and if this health insurance is banished this would affect millions of Americans. It has been stated so many times that the law will reduce the nation's deficit by more than $100 billion by 2020 and by $1 trillion by 2030. So far there is no evidence to find this statement true. It has been hard to find any positive information on the bill thus far (Refer to Table 4, page 19 for a Pros and Cons list). The health care system in the United States has been a subject of debate for many years as well as the topic of campaign pledges by many who have run for office. Not long ago, in fact, President Obama made a campaign promise to make better and more health care services

Affordable Care Act Page 4 of 25 inexpensive for all. The Affordable Care Act (ACA), which was passed in March 2010, will be phased in over the next four years (refer to Table 3 on page 15). These next few statements are statements that the Obama administration wants the Americans to believe is going to take place with this new health care plan. Such as, dozens of very important provisions have been applied already, including small business tax credits, the Medicare recipient drug rebate, the reinsurance program for retiree coverage, the pre-existing condition insurance plans, the coverage of children up to age 26 on their parents’ plans, and many more. The current administration wants it to seem like that whether you get insurance through work, buy it yourself, have a small business, are on Medicare, or don't currently have insurance, the Affordable Care Act gives you control to make your own decisions regarding your health coverage. It is said that the Affordable Care Act makes insurance more affordable by providing the largest middle class tax cut for health care in history - dropping premium costs for millions of families and small business owners who are priced out of coverage today. In turn this is supposed to help 32 million Americans afford health care and make coverage more affordable for many more. According to Veronique de Rugy in an article titled “Does Obamacare Reduce Health Care Spending?” The short answer is no. Using the Congressional Budget Office (CBO) data, Figure 1 shows that the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 have left the cost curve of federal healthcare spending virtually unchanged over the next 25 years. The CBO finds that the effect of the healthcare legislation has been to increase

Affordable Care Act Page 5 of 25 government spending by $3.8 trillion between 2010 and 2020. From 2020 to 2035, federal spending under the two projections are equal percentages of GDP.” The Patient Protection and Affordable Care Act, as improved by the reconciliation bill, is said to ensure that all Americans have access to quality, inexpensive health care and will produce the modification within the health care system needed to contain costs. A popular opinion is that this trillion dollar takeover of health care will just make things worse for Americans.

FIGURE 1 – CBO Data Showing Projected Effects on Healthcare Costs

The plan will add hundreds of billions of dollars to the deficit. It would also mean new taxes and a huge backdoor premium that will make health care costs even higher, not lower. Businesses and taxpayers will be stuck paying for a government run plan through higher taxes, these costs are cost that no one can afford at this time when the economy is facing real challenges.

Affordable Care Act Page 6 of 25 With so many challenges and problems that so many families are already facing, the healthcare bill would be another burden for a family, as well as a business. Table 1 lists changes that will take affect with premiums under the new healthcare bill. According to Michael Tanner in an article (Bad Medicine 2011), he states, “the biggest businesses, those with more than 100 employees, would see the biggest benefit under PPACA, but even here the benefit would be minimal. Under the best case scenario, the premiums for a family plan would only increase to $20,100, compared with $13,375 today, and $20,300 if the bill hadn’t passed. That represents a savings of $200 over what would have happened if the bill had not passed, but still represents a $6,350 increase over what the company is paying today. Small businesses would see a premium increase between zero and just 1 percent less than would otherwise occur. Then again under the best-case scenario, small business premiums for a family plan would only increase to $19,200, compared to $19,300 if the bill hadn’t passed, a savings of just $100. But the millions of Americans who purchase insurance on their own through the non-group market will actually be worse off as a result of this law.” TABLE 1 – PPACA Premium Costs

The new health care reform will cover fewer medical procedures and each American will have long waiting periods before they can get the medical care they seriously need. Under this

Affordable Care Act Page 7 of 25 plan if you need surgery or a transplant it may take so long for the government to O.K. the medical procedure that one might need, that that person may die before the treatment is approved. Other countries with this same government run plan has put price tags on the lives of their citizens. This health care plan oversees your care and it makes the ill patients wait for the critical care they need to survive. When the reform starts to play a huge role in the medical field, it will not be a surprise that the demand for medical services to increase with the health care reform proposal. Anyone can buy insurance without limitations on pre-existing conditions. The people will likely utilize more services because now they will have the insurance to go to the doctor more often. Even though most disadvantaged people did have some access to health care even before reform, it's different when you know you can walk in and be treated like a regular insured person. This reform will increase the demand for medical services. According to MSNBC (2011), “the House Republicans have voted to begin the work of replacing President Barack Obama's landmark law that expands health insurance coverage.” The huge wave of smaller-government response that crashed down on the Washington authorities has been building for a long time, picking up steam with each passage of legislation that prolonged the government’s violation into the lives of the American people. Central to all of this has been the conflict surrounding health care reform. The bill creates within the federal government a nationwide Health Insurance Exchange. It has been stated that the uninsured individuals would

Affordable Care Act Page 8 of 25 be free to purchase an Exchange plan, as would those whose existing employer coverage is considered lacking by the federal government. Once considered eligible to enroll in the Exchange, individuals would be allowed to remain in the Exchange until becoming Medicare eligible. According to a letter addressed to, The Members of the U.S. House of Representatives, written by R. Bruce Josten (2010); “The U.S. Chamber of Commerce, the world’s largest business federation representing the interests of more than three million businesses and organizations of every size, sector and region, strongly opposes the Senate-passed version of H.R. 3590, the Patient Protection and Affordable Care Act. The bill is fundamentally flawed as its underlying framework is the wrong approach to health reform.” According to the U.S. Chamber of Commerce there are several problems with H.R. 3590 and they are as follows: “Employer Mandate: The bill creates a damaging new mandate on employers that would force them either to offer a government-mandated level of coverage or be liable for significant new taxes; New Taxes: The bill imposes nearly $500 billion in new taxes, many of which would fall squarely on small businesses. Taxes on medical devices and prescriptions would be passed through to consumers. Taxes on insurance plans would be passed on directly to small businesses, as large self-insured employers are exempt; Dangerous Entitlements and Medicare Cuts: The bill cuts approximately $500 billion from Medicare. However, despite double-counting by the Congressional Budget Office (CBO), this money will not be used to shore up the Medicare trust fund, which is projected to be bankrupt by 2017. Rather, it will be used to create a vast new entitlement that will transfer government funds to families making up to $88,000 a year; Expensive Plan Requirements: Every health plan will be required to meet certain standards set by the federal government, except for “grandfathered plans,” which the President’s proposal essentially eliminates. The end result of these new requirements,

Affordable Care Act Page 9 of 25 according to CBO, is that health insurance on the individual market will be 10-13% more expensive if H.R. 3590 is enacted, than if nothing is done; Weak Cost Containment: The bill would do little to lower costs and for many would in fact increase them, which is in part because numerous common-sense cost-containments approaches are not included in the legislation. o The bill contains only an inconsequential “sense of the Senate” nod to medical liability reform, despite CBO’s finding that caps on punitive damages for doctors could save $54 billion for the government and untold amounts for the private sector. o The bill does not allow all Americans to purchase health insurance across state lines, which the CBO found would lower health care costs by 5%. o The bill does not allow new small business pooling arrangements, which the CBO found would not only increase coverage, but would also save money for the federal government and the states by getting people off the Medicaid program and into employer-sponsored plans. o The bill would do nothing to curtail state benefit mandates that drive up the costs of health insurance for small business. o The bill would not make changes to successful high-deductible health plan models to help them work better with innovative care concepts like patientcentered medical homes. o Lastly, the bill would not do enough to move away from fee-for-service and toward outcome- and quality-based reimbursement for medical providers; and Unworkable Small Business Tax Credits: Because of the extremely low wage restrictions for small businesses to be eligible for credits, hardly any small businesses would be eligible. Those businesses that are eligible would be required to offer highly comprehensive plans and pay the vast majority of the employees’ premiums – and after two or three years, the credit would vanish entirely, leading to an immediate spike in a small businesses’ cost. These factors make it highly unlikely that most small businesses would, or would be able to, take advantage of this credit.”

Affordable Care Act Page 10 of 25 The Chamber of Commerce stated that there are several problems with the bill, H.R. 3590 and those problems were stated very bluntly in the letter addressed to the U.S. House of Representatives in March 2010. The bill was actually passed in March 2010, so this statement tells me that even before the bill was passed, the problems were addressed to the senate but the bill was still passed. As more than half of all high-income filers are small businesses, this bill would cripple small businesses and destroy jobs during a deep recession. Many may be concerned that this provision would lead to many companies dropping their current coverage as a result. According to Curtis Dubay, in an article called, Obamacare and New Taxes: Destroying Jobs and the Economy (2011), it discussed how, “ the Patient Protection and Affordable Care Act (PPACA) imposes numerous tax hikes that transfer more than $500 billion over 10 years— and more in the future—from hardworking American families and businesses to Congress for spending on new entitlements and subsidies.” This bill contains 18 separate tax increases (listed in Table 2), which in the long run will cost taxpayers $503 billion between 2010 and.2019. According to Bussinessweek.com, “two weeks after Republicans took control of the House in January 2011; they kept a key campaign promise and voted to repeal President Barack Obama's health-care law. The Democratic Senate later rejected the repeal, but House Republicans say they still plan to "replace Obamacare with something that's a lot better. Their focus is to lower the cost of care” (Lerer et al., 2011). When the Republicans went in keeping a promise to the people and voted to repeal this bill, I feel as though they should have gone in with a better plan rather than just going in with nothing to offer as a trade. In a recent article by Jason Millman (2011), it was stated that the “republicans are also challenging how much authority Sebelius has to alter a new long-term care insurance program, which she acknowledges is “totally unsustainable” in its

Affordable Care Act Page 11 of 25 current form. But Republicans are pointing to a new Congressional Research Service (CRS) that questions just how much power Sebelius has to make changes to the voluntary program. TABLE 2 – Obama Care Taxes (ref: heritage.org)

Affordable Care Act Page 12 of 25 The CRS report said a court may find the sweeping healthcare reform law does not provide the HHS secretary with the authority to raise minimum earnings requirements in order to be eligible for the program.” While the Secretary will be required to "negotiate" reimbursement rates with doctors and hospitals, nothing in the law prohibits the Secretary from using such cooperation to enforce Medicare reimbursement levels on providers as part of a government-imposed "negotiation." The law requires the Secretary to "establish conditions of participation for health care providers" under the government-run plan-however it includes no guidance or conditions under which the Secretary must establish those conditions. Many may be concerned that the bill would allow the Secretary to prohibit doctors from participating in other health plans as a condition of participation in the government-run plan. Both Virginia and Florida have challenged the act’s requirement that individuals must carry health insurance as unconstitutional. Twenty-four other states have signed onto the lawsuit as plaintiffs. According to Becker’s Hospital Review.com (2011), here are “13 legal issues affecting hospitals and health systems in 2011”: Lawsuits against the mandate to buy health insurance, HIPAA and data breaches, Antitrust issues and ACOs, False claims and whistleblower suits, Anti-Kickback and physician-hospital issues, Impact of Stark Law on physician-hospital relationships, Recovery audit contractors, Compliance requirements for tax-exempt hospitals,

Affordable Care Act Page 13 of 25 Co-management arrangements, Changes in reimbursement, Labour and employment issues, Mergers and antitrust law, and Medical malpractice and tort reform. The question of whether the Health Care Reform is constitutional is a hot topic in today’s society. The answer to this question is different based on the individual who answers it and which way their political views lean. Republicans would state no, while Democrats would most likely argue yes. At the present time, the majority of individuals are stating that it is not constitutional. The president and the Democratic congressional leadership are fighting frantically to pass, with no Republican votes, the ever-less-popular health bill. On the short end of the vote, Democrats challenged Republican claims and highlighted politically popular elements of the bill that would be wiped out if repeal took effect. With all the arguing going on between Democrats and the Republicans, the Republicans have been accused of hypocrisy by voting to repeal a vast expansion of health care at the same time they had signed up for coverage for their families through a government-organized program available [only] to lawmakers. While the Republican-led House can pass legislation to repeal, the Senate, where the Democrats presently hold a 53 to 47 advantage, is less likely to collect the votes to pass similar legislation. Even if the a few embattled Senate Democrats were pulled over to the Republican side, there would not be enough of the 66 votes required to overcome a Presidential veto. The more realistic track will be the defunding effort that will take place as components of the Act are brought up for implementation funding. The House can simply hold up funding by refusing

Affordable Care Act Page 14 of 25 appropriations or tying things up in committee hearings. While this is a slower process, it can also cause a lot more pain by drawing out all of the Act’s defects holding them up to public scrutiny, which never really occurred during its backdoor passage.

In the end, the
Affordable Health Care Act may not be repealed during this current session of Congress, but it will be starved, scrutinized and assaulted in such a way that it will remain as a political ball and hammer for pro-reform candidates in the next election. According to James Oliphant of the Los Angeles Times, “the public’s attitude toward the law, however, has not shifted much at all. The Affordable Care Act remains almost as equally loathed and celebrated as it was 12 months ago, despite the best efforts of Democrats to praise it and Republicans to bury it. Even worse for both sides, a majority of Americans remain confused about what the law actually accomplishes”. Table 3 lists the major provisions/timetable of the Affordable Care Act and Table 4 summarizes perceived pros and cons. If left standing, the law’s overall effect on business growth and prosperity in this country is certainly controversial. But, most do agree that the result would be monumental and historic, regardless of the net economic outcome.

Affordable Care Act Page 15 of 25 TABLE 3 PROVISIONS OF THE AFFORDABLE CARE ACT, BY YEAR YEA R 2010 TOPIC
NEW CONSUMER PROTECTIONS

INFORMATION
Putting Information for Consumers Online. Prohibiting Denying Coverage of Children Based on PreExisting Conditions.

IMPLEMENTATION DATE
Effective July 1, 2010. 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. Eliminating Lifetime Limits on Insurance Coverage. Regulating Annual Limits on Insurance Coverage.

Effective for health plan years beginning on or after September 23, 2010. Effective for health plan years beginning on or after September 23, 2010. Effective for health plan years beginning on or after September 23, 2010.

Appealing Insurance Company Decisions.

Effective for new plans beginning on or after September 23, 2010.

Establishing Consumer Assistance Programs in the States. IMPROVING QUALITY AND LOWERING COSTS Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug “Donut Hole. Providing Small Business Health Insurance Tax Credits.

Grants Awarded October 2010. Effective now.

First checks mailed in June, 2010, and will continue monthly throughout 2010 as seniors hit the coverage gap.

Providing Free Preventive Care.

Effective for health plan years beginning on or after September 23, 2010.

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Preventing Disease and Illness. Cracking Down on Health Care Fraud. INCREASING ACCESS TO AFFORDABLE CARE Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. Extending Coverage for Young Adults. Effective for health plan years beginning on or after September 23. Expanding Coverage for Early Retirees. Applications for employers to participate in the program available June 1, 2010. Rebuilding the Primary Care Workforce. Holding Insurance Companies Accountable for Unreasonable Rate Hikes. Allowing States to Cover More People on Medicaid. Increasing Payments for Rural Health Care Providers. Strengthening Community Health Centers. Effective April 1, 2010. Effective 2010. Effective 2010. Effective January 1, 2011. Effective 2010. Grants awarded beginning in 2010. Funding begins in 2010. Many provisions effective now. National program effective July 1, 2010.

2011

IMPROVING QUALITY AND LOWERING COSTS

Offering Prescription Drug Discounts.

Providing Free Preventive Care for Seniors. Improving Health Care Quality and Efficiency.

Effective January 1, 2011. Effective no later than January 1, 2011.

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Improving Care for Seniors After They Leave the Hospital. Introducing New Innovations to Bring Down Costs. Effective January 1, 2011. Administrative funding becomes available October 1, 2011. INCREASING ACCESS TO AFFORDABLE CARE HOLDING INSURANCE COMPANIES ACCOUNTABLE Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Effective January 1, 2011. Bringing Down Health Care Premiums. Effective January 1, 2011. Increasing Access to Services at Home and in the Community. Effective beginning October 1, 2011.

2012

IMPROVING QUALITY AND LOWERING COSTS

Linking Payment to Quality Outcomes.

Effective for payments for discharges occurring on or after October 1, 2012.

Encouraging Integrated Health Systems. Reducing Paperwork and Administrative Costs. Understanding and Fighting Health Disparities. INCREASING ACCESS TO AFFORDABLE CARE Providing New, Voluntary Options for Long-Term Care Insurance. Improving Preventive Health Coverage.

Effective January 1, 2012. First regulation effective October 1, 2012. Effective March 2012. The Secretary shall designate a benefit plan no later than October 1, 2012. Effective January 1, 2013.

2013

IMPROVING QUALITY AND LOWERING COSTS

Expanding Authority to Bundle Payments.

Effective no later than January 1, 2013.

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

2014

NEW CONSUMER PROTECTIONS

Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. Eliminating Annual Limits on Insurance Coverage. Ensuring Coverage for Individuals Participating in Clinical Trials.

Effective January 1, 2014.

Effective January 1, 2014. Effective January 1, 2014. Effective January 1, 2014. Effective January 1, 2014. Effective January 1, 2014. Effective January 1, 2014.

IMPROVING QUALITY AND LOWERING COSTS

Making Care More Affordable. Establishing Health Insurance Exchanges. Increasing the Small Business Tax Credit.

INCREASING ACCESS TO AFFORDABLE CARE

Increasing Access to Medicaid.

Promoting Individual Responsibility. Ensuring Free Choice.

Effective January 1, 2014. Effective January 1, 2014. Effective January 1, 2015.

2015

IMPROVING QUALITY AND LOWERING COSTS

Paying Physicians Based on Value Not Volume.

Affordable Care Act Page 19 of 25 TABLE 4 - PROS AND CONS LIST

PRO Health Care Reform Law

CON Health Care Reform Law

1. Keeping Insurance Coverage
PRO: "No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.” Barack H. Obama, JD
44th President of the United States Address to the annual meeting of the American Medical Association, June 15, 2009

CON: "According to experts, more than 87 million American could lose access to their current health care plan under the new law. Workers at a majority of the nation’s employers – including as many as four out of every five small businesses – would lose their current coverage, thus providing further evidence that ObamaCare is doing exactly the opposite of what Democrats promised it would do." John Boehner
Minority Leader of the United States House of Representatives (ROH) "Obamacare, Three Months of Broken Promises," www.gopleader.gov, June 23, 2010

2. Quality of Care Improvements
PRO: "Patient care under Medicare will improve as pilot programs to improve efficiencies are implemented. Doctors and hospitals are encouraged to coordinate care through payment incentives. For the first time, Medicare will reward quality, not quantity; thus, bonus payments will be given to those doctors and hospitals that provide good quality care." Alliance for Retired Americans (ARA) "Medicare Benefits and Changes," www.retiredamericans.org, Apr. 2010 CON: "...[O]ur care will suffer. If the Democrats' plans become law, fewer than 700,000 physicians would be available to treat a patient population growing in size, aging in years, shunning medical education and receiving 'free' health care or insurance coverage from the government in increasing numbers. The result will be longer wait times to see a doctor and a decline in the high quality of care Americans are accustomed to as overworked physicians try to keep up." Investor's Business Daily "The Doctor Shortage," www.investors.com, Mar. 4, 2010

3. Private Health Insurance VS. Socialism
PRO: "Opponents of health insurance reform continue to spread myths, including peddling the bogus notion that the health reform bill is 'socialism' and a 'government takeover of health care.' The fact is the reform legislation builds on our existing private health insurance system... [H]ealth insurance reform legislation expands private health insurance in America, and is based on increasing choice and competition... among a variety of private insurance plans." CON: "Obama is a socialist. If you take over banks, if you take over car companies, if you take over financial institutions, the way that he has - now the health care system. If you're going to use every crooked deal that you can come up with to get a bill like that passed - most recently the health care bill - that is by definition, if you look up the dictionary definition of socialism, this is it.” Sean Hannity
Host of Fox News Channel’s Hannity show Interview with CNSnews.com, Mar. 25, 2010

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Nancy Pelosi
Speaker of the US House of Representatives (D-CA) "Health Insurance Reform Mythbuster - 'Democrats' Health Insurance Refrom Is Socialism and a Government Takeover," www.speaker.gov, Mar. 19, 2010

4. Constitutionality
PRO: "The Constitution gives Congress the power to tax and spend money for the general welfare. This tax [PPACA] promotes the general welfare because it makes health care more widely available and affordable. Under existing law, therefore, the tax is clearly constitutional... Many important and popular government programs are based [on] Congress's ability to give incentives through taxation and redistribute tax revenues for public purposes. To strike down the individual mandate the Supreme Court would have to undermine many years of precedents justifying these programs that stretch back to the New Deal (and in the case of the rules for direct taxes, to the very founding of the country). Opponents of the individual mandate insist that they are only defending individual freedom, but they are actually taking a far more radical position. They are really claiming that it is unconstitutional to make Americans pay taxes." Jack M. Balkin, JD, PhD
Knight Professor of Constitutional Law and the First Amendment at Yale Law School "Is the Health Care Law Unconstitutional?," New York Times, Mar. 28, 2010

CON: "Can Congress really require that every person purchase health insurance from a private company or face a penalty? The answer lies in the commerce clause of the Constitution, which grants Congress the power 'to regulate commerce... among the several states.' ...[T]he individual mandate extends the commerce clause's power beyond economic activity, to economic inactivity. That is unprecedented. While Congress has used its taxing power to fund Social Security and Medicare, never before has it used its commerce power to mandate that an individual person engage in an economic transaction with a private company. Regulating the auto industry or paying 'cash for clunkers' is one thing; making everyone buy a Chevy is quite another. Even during World War II, the federal government did not mandate that individual citizens purchase war bonds." Randy E. Barnett, JD
Carmack Waterhouse Professor of Legal Theory at the Georgetown University Law Center "Is Health-Care Reform Constitutional?," Washington Post, Mar. 21, 2010

5. Insurance Premium Reductions
PRO: "We estimate that, on net, the combination of provisions in the new law will... lower premiums by nearly $2,000 per family... Without reform, premiums are expected to increase from $13,305 in 2010 to $21,458 in 2019. Relative to this increase, premiums under reform increase only threequarters as much. By 2019, family premiums are nearly $2,000 lower. Adding reductions in out-of-pocket costs and lower taxes for Medicare and Medicaid will result in estimated savings for the typical family of over $2,500 that year." Center for American Progress (CAP) "The Impact of Health Reform on Health System Spending," www.americanprogress.org, May 2010 CON: "Throughout the year-long debate over health care reform, President Obama promised that the legislation would reduce the spiraling cost of health care... But a couple of new government reports confirm what many of us who opposed a federal takeover of the health care system feared all along higher costs... CMS [Centers for Medicare and Medicaid Services] says that the health care law will impose billions of dollars in annual fees on manufacturers and importers of brand-name prescription drugs and on health insurance plans, and new taxes on medical device sales. CMS said it anticipates that these new fees and taxes will be passed down to consumers in the form of higher drug and device prices and higher insurance premiums, raising health care costs from $2.1 billion in 2011 to $18.2 billion in 2018. Throughout the health care debate, Americans were told the Democrats' health care reform measure would

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make premiums more affordable; instead, as the President's own actuary at CMS confirms, Americans will face higher premiums..." Lisa Murkowski, JD US Senator (R-AK), New Health Care Law Will Increase Costs, Reduce Benefits," murkowski.senate.gov, May 18, 2010

6. Medical Bankruptcy Prevention
PRO: "The Senate plan limits how much even the wealthiest family buying insurance in the Exchange can be expected to pay, out-of-pocket, in a given year to a total of $11,900 for a family, and $5,950 for an individual. Again, lower-income households are expected to pay less… These caps should virtually eliminate medical bankruptcy. The total amount that a family can possibly owe is low enough that providers will be willing to give them time to pay it off, and in many cases, to negotiate discounts. When providers know that there is no way that you can ever pay a $50,000 bill, you wind up in bankruptcy court. When the amounts are smaller, and doable over time, negotiations are possible." Maggie Mahar, PhD
Fellow at the Century Foundation Response to Paul Starr's article "What Is in the Health Care Bill," www.talkingpointsmemo.com, Dec. 17, 2009

CON: "Most people with medical bankruptcies already have insurance, and out-of-pocket expenses will continue to be a burden on the middle class. • • • • • • In 2009, 1.5 million Americans declared bankruptcy Of those, 62% were medically related Three-quarters of those had health insurance The Obama bill leaves 24 million without insurance The maximum yearly out-of-pocket limit for a family will be $11,900 on top of premiums A family with serious medical problems that last for a few years could easily be financially crushed by medical cost

Real health care reform is needed. But this bill falls short of that on many levels." Jane Hamsher, MFA
Founder and Publisher of Firedoglake "Fact Sheet: The Truth About the Health Care Bill," www.huffingtonpost.com, Mar. 19, 2010

7. Federal Deficit Reduction
PRO: "CBO [Congressional Budget Office] and JCT [Joint Committee on Taxation] estimate that enacting both pieces of legislation—H.R. 3590 and the reconciliation proposal—would produce a net reduction in federal deficits of $143 billion over the 2010–2019 period as result of changes in direct spending and revenues. That figure comprises $124 billion in net reductions deriving from the health care and revenue provisions and $19 billion in net reductions deriving from the education provisions." Congressional Budget Office (CBO)
Report (untitled) on the estimated budgetary effects of the March 2010 health care reform laws, www.cbo.gov, Mar. 20, 2010

CON: "In reality, if you strip out all the gimmicks and budgetary games and rework the calculus, a wholly different picture emerges: The health care reform legislation would raise, not lower, federal deficits, by $562 billion..." Douglas Holtz-Eakin, PhD
President of the American Action Forum and former Director of the Congressional Budget Office "The Real Arithmetic of Health Care Reform," New York Times, Mar. 20, 2010

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8. Tax Reductions
PRO: "The health reform legislation signed into law by President Obama includes the largest health care tax cut in history for middle class families, helping to make insurance much more affordable for millions of families... The Small Business Health Care Tax Credit can cover up to 35 percent of the premiums a small business pays to cover its workers. In 2014, the rate will increase to 50 percent..." Dan Pfeiffer
White House Communications Director "Health Reform and the Recovery Act: Unprecedented Tax Cuts for the Middle Class," www.whitehouse.gov, Apr. 13, 2010

CON: "The Senate bill would: impose job-killing mandates and penalties on businesses, [and] increase taxes and burdens on small businesses... H.R. 4872 is no 'fix' for the Senatepassed bill. It includes a long term hidden tax by deferring the 'Cadillac tax' on certain high cost health plans until 2018. The number of Americans that will ultimately suffer from this hidden tax will mushroom each year because the tax is indexed to inflation... This bill would also impose a new 3.8 percent 'Medicare tax' on non-wage income that would target high income earners, income from interest, dividends, capital gains, and some profits from investments in partnerships and S-corporations. If this tax and other tax increases included in the President's FY 2011 budget become law, certain taxpayers could expect a marginal tax rate on capital gains and qualified dividends of 23.8 percent, and a marginal tax rate on nonqualified dividends of 43.4 percent." US Chamber of Commerce
"H.R. 3590, the 'Patient Protection and Affordable Care Act,' and the Related Budget Reconciliation Legislation, H.R. 4872, the 'Student Aid and Fiscal Responsibility Act of 2009,'" www.library.uschamber.com, Mar. 19, 2010

9. Fixing the Physician Shortage
PRO: "The recently enacted PPACA (H.R. 3590) includes numerous policies to train more primary care physicians and increase the supply of primary care physicians. These policies include: mandatory and increased discretionary funding for the National Health Service Corp (NHSC), reauthorization of Section 747 of Title VII, Training in Family Medicine, General Internal Medicine, General Pediatrics, and Physician Assistantship; creation of a Primary Care Training Extension Program and increased faculty scholarship loans, redistribution of 65% of the current unused Graduate Medical Education slots to primary care and general surgery and allowing residents to count their time spent in ambulatory settings to count towards their residency requirements, such as physician offices and community health centers; and the establishment of Teaching Health Centers, creating primary care residency programs in non-hospital settings." American College of Physicians (ACP)
"Ensuring an Adequate Supply of Primary Care Internists and Other Specialties Facing Shortages," www.acponline.org, Apr. 7, 2010

CON: "Questions have been raised as to whether there will be a sufficient supply of physicians and other health professionals to serve the nation, especially in light of concerns that the nation was facing potentially significant shortages even before health care reform... [W]e project an overall shortage of 91,500 and 130,600 active patient care physicians in 2020 and 2025 respectively, and a primary care shortage of 45,400 and 65,800 physicians in 2020 and 2025... These revised estimates are consistent with earlier estimates: they indicate the health care system is likely to be facing severe pressure as demand rises more rapidly than the supply." Association of American Medical Colleges (AAMC)
"The Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025," www.aamc.org, June 2010

Affordable Care Act Page 23 of 25

10. Medical Malpractice Lawsuits
PRO: "As part of a 'grand bargain' to create a bipartisan health care bill, some have said tort reform should be included... Look at what the actual data says: 98,000 people dead every year from preventable medical errors, at a cost of $29 billion. Countless more are seriously injured with astronomical costs. The Congressional Budget Office and Government Accountability Office have looked at tort reform multiple times, and said it will save practically no money. They also found no evidence of so-called 'defensive medicine,' finding that doctors run more tests because of the fee-for-service structure, or because of the benefits extra tests have on patient care. Additionally, a 2006 study from Harvard found that 97% of cases were meritorious, totally debunking the idea that frivolous lawsuits plague our courts. And while 46 states have enacted some kind of tort reform, health care costs have continued to skyrocket, while injured patients or their families often can't seek justice... Forty-six states have tort reform, and American families still shoulder exorbitant health care costs. All the facts and data say it doesn't work. There's still 98,000 people dead every year from medical errors. But when political gamesmanship and backroom deals take over, the facts fly out the window. This health care bill has a long way to go. But let's be perfectly clear: patients' rights aren't negotiable. Tort law changes won't fix health care, but only make it more difficult for injured patients to seek justice. Instead of bargaining away patients' rights, Congress should [put] their safety first." Anthony Tarricone, JD
Former President of the American Association of Justice "Tort Reform: A Bad Bargain That Won't Fix Health Care," www.huffingtonpost.com, Sep. 22, 2009

CON: "You would think that any effort to reform our health care system would include tort reform, especially if the stated purpose for Obama’s plan to nationalize our health care industry is the current high costs... Many states, including my own state of Alaska, have enacted caps on lawsuit awards against health care providers. Texas enacted caps and found that one county’s medical malpractice claims dropped 41 percent, and another study found a '55 percent decline' after reform measures were passed. Texas Gov. Rick Perry noted that, after his state enacted tort reform measures, the number of doctors applying to practice medicine in Texas 'skyrocketed by 57 percent' and that the tort reforms 'brought critical specialties to underserved areas.' These are real reforms that actually improve access to health care. ...[R]esearch shows that around $200 billion per year could be saved with legal reform. That’s real savings. If you want to save health care, let’s listen to our doctors. There should be no health care reform without legal reform. There can be no true health care reform without legal reform." Sarah Palin
Former Governor of Alaska "No Health Care Reform Without Legal Reform," www.realclearpolitics.com, Aug. 21, 2009

Affordable Care Act Page 24 of 25 REFERENCES Dubay, C. (20, January 2011). Obamacare and new taxes: Destroying jobs and the economy. WebMemo. The Heritage Foundation. Retrieved on April 18, 2011, from http://thf_media.s3.amazonaws.com/2011/pdf/TheCaseAgainstObamacare.pdf Josten, R. B. (12, March 2010). Chamber of Commerce of the United States of America. Executive Vice President Government Affairs. Retrieved on March 29, 2011 from http://www.uschamber.com/sites/default/files/issues/health/files/100312hr3590patientpro tectionaffordablecarehouse.pdf Lerer, L. and Armstrong, D. (24, March 2011). The republican response to Obamacare politics & policy. Businessweek.com. Retrieved on March 29, 2011 from http://www.businessweek.com/magazine/content/11_14/b4222037389678.htm Millman, J. (28, March 2011). GOP questions HHS authority to grant healthcare waivers. The hill.com. Retrieved on March 30, 2011 from http://thehill.com/blogs/healthwatch/healthreform-implementation/152113-gop-raises-new-questions-about-healthreform?page=1#comments MSNBC. (20, Jan. 2011). GOP's health care repeal: Now for the hard part. House Republicans won a symbolic victory, but now face a wall of opposition in the Senate. MSNBC.com. Retrieved on March 29, 2011 from http://www.msnbc.msn.com/id/41171439/ns/politicscapitol_hill/ Oliphant, J. (23, March 2011). Healthcare laws condition is anything but stable on its anniversary. Los Angeles Times. Retrieved on March 24, 2011 from http://www.latimes.com/health/healthcare/la-pn-healthcare-law-20110324,0,293235.story

Affordable Care Act Page 25 of 25 REFERENCES (CONCLUDED) Page, L. and Fields, R. (14, March 2011). 13 Legal Issues for Hospitals and Health Systems. Becker Hospital Review.com. Retrieved on March 28, 2011 from http://www.beckershospitalreview.com/hospital-financial-and-business-news/13-legalissues-for-hospitals-and-health-systems.htm ProCon.org. (2010, September 1). Top 10 Pros & Cons. HealthCareReform.ProCon.org. Retrieved on April 17, 2011 from http://healthcarereform.procon.org/view.resource.php?resourceID=003725 Rugy, V. (4, November 2010). Does ObamaCare reduce health care spending? The short answer is no. Reason.com. Retrieved on April 17, 2011 from http://reason.com/archives/2010/11/04/does-obamacare-reduce-health-c Tanner, M. (2011). Bad Medicine: A guide to the real costs and consequences of the new health care law. Cato.org. Cato Institute. Retrieved on April 17, 2011 from http://www.cato.org/pubs/wtpapers/BadMedicineWP.pdf

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