Patient Protection and

In your discussion:

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Use the KFF videos and factsheets as background information only. They were done BEFORE the law went into full effect, so they are based on intended goals and objectives
Focus your 3 discussion points on your review of the articles in “Implementation” (3 articles) and “Repeal”
In your post, include both positive and negative effects of the bill for each point and limit your discussion to information provided in the reading
Your discussion should be consistent with the content of the references that you cite

First point
(please take this point and rewrite the first paragraph same as what they discussed; it does not have to be focused in nursing)
((I copied this from the first article article please paraphrased and cite it)) Patient Protection and Affordable Care Act of 2010 Essay
((The ACA directed CMS to test and implement new approaches for Medicare to pay doctors, hospitals, and other providers to bring about changes in how providers organize and deliver care. The ACA authorized the Secretary of Health and Human Services to expand CMMI models into Medicare if evaluation results showed that they either reduced spending without harming the quality of care or improved the quality of care without increasing spending. CMMI received an initial appropriation of $10 billion in 2010 for payment and delivery system reform model development and evaluation, and the ACA called for additional appropriations of $10 billion in each decade beginning in 2020, The ACA also created incentives for hospitals to reduce preventable readmissions and hospital-acquired conditions, and established new accountable care organizations (ACO) programs. Research has shown declines in Medicare patient readmissions since the Hospital Readmission Penalty Program provisions were introduced))
The act will hold several advantages:
(Please talk about cost effective, care quality, time saving and preventing unnecessary test for patients)
One of the benefits is that it will enhance the wellness and health of the Medicare population. It will also improve the quality of care offered by the health care team. The insurance will also amend the lower cost of medical care accompanied by shared savings.
Negative impact: (please talk about that the HCP may overlook necessary diagnostic measurements because they are focusing in cost reduction).
Every person has to be insured
((I copied this from the second article page 4 please paraphrased and cite it))
((With certain statutory or administrative exceptions all Americans are legally required to provide or enroll in federally approved insurance coverage or pay a tax penalty for refusing to provide such coverage as an employer or to enroll in such coverage as an individual. Federal officials enforce rules governing insurance rating, co-payments and deductible levels, and allowable profit and administrative expenses. Private health insurance is “private” in name only))
ACA law will require nurses to offer education to their clients. The clients will need to be notified on the deadlines of acquiring coverage for individuals and families to avoid being penalized. This will be a crucial strategy to prevent clients from being overwhelmed by substantial season taxes compiled over many unpaid seasons. The possible penalties on the tax preparers which are not compliant together with ACA procedures must be made known. Patient Protection and Affordable Care Act of 2010 Essay
Positive impact: Educating clients on insurance coverage and the taxpaying system of the ACA act will be very crucial. The law will also boost the nurse’s careers. Additionally, the nurse-to-patient ratios may drastically change due to more people seeking health attention. It will force more American citizens to insure themselves and their families. Besides, the clients will be made aware of the paying systems and the potential repercussions of not being covered by coverage. The demand for new providers will increase, meaning that APRN will be prone to a lot of job opportunities as well as other health care providers.
negative impact on nurses. (talk about the hospital will be busy due to increase patients demand for health care since they become insured. Also, HCPs may need to work overtime to cover patients need)
Third point:
((I copied this from the second article page 21 please paraphrased and cite it))
((Effective in 2010, the ACA prohibited insurers from offering limited-benefit “mini-med” plans. Because these plans did not meet the 2010 federal standards for coverage caps, the plans’ officials either had to raise their rates to comply, making them less affordable for low- income persons who enrolled in them, or go out of business and thus deny those persons access to that coverage.
The problem was that thousands of retail and service industry companies, various organizations, and even unions offered these plans, and an estimated 4 million Americans were enrolled in them.))
Positive: slandered high people will insure having good converge
Negative: many people cannot offer those insurance plans. Thus, low income people will be uninsured

Americans are engaged in an intense national debate over the Patient Protection and
Affordable Care Act of 2010 (ACA, popularly known as “Obamacare”). Despite President
Barack Obama’s glowing account of his “signature” accomplishment, the ACA’s six-year
record demonstrates that the legislative product he signed into law is deeply—and in many
respects irreparably—flawed. Obamacare is bedeviled by poor performance in a number of
vital areas:
Increased costs for individuals, families, and businesses;
Resumption of excessive health care spending and middle-class taxation; and
A seemingly endless series of managerial failures or unanticipated consequences.Patient Protection and Affordable Care Act of 2010 Essay
The ACA is a formidable engine of concentrated bureaucratic power and control, yet its future
is clouded by persistent unpopularity.
Persistent Unpopularity
The ACA was the product of a narrowly partisan process. Before final passage, during the
months of February and March 2010, not one major survey recorded majority support for the
legislation. In the congressional elections of 2010 and 2014, during which the law was a
major issue, opponents were overwhelmingly victorious at the polls.
[1]
[2]
After securing enactment of the law in the teeth of popular opposition, Administration
officials and their allies in Congress and elsewhere repeatedly claimed that the American
people would come to like the ACA over time.[3] Yet, according to a recent compilation of

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survey data from RealClear Politics, 49.3 percent of Americans oppose the law compared to
39 percent who favor it.[4]
This is not surprising. In 2011, Heritage Foundation analysts, in a series of 15 papers covering
the ACA’s main provisions, outlined the law’s likely impact on the financing and delivery of
care. By 2014, many of those predictions had come true. In fact, the prospect of rising
costs, disruption of existing coverage, and metastasizing bureaucracy—dynamics that also
doomed the Medicare Catastrophic Coverage Act of 1988 and undermined the Clinton health
plan of 1993—have characterized the ACA’s rocky implementation.Patient Protection and Affordable Care Act of 2010 Essay
[5] [6]
[7]
Practical Concerns
Americans’ health care worries are real, and their concerns are practical. For the
overwhelming majority of Americans, the right policy goal is making health care more
affordable. Today, however, the “typical family” pays about 35 percent of their income for
health care. The temporary slowdown in health spending, which started in the early 2000s,
is over, and businesses, individuals, and families are once again threatened with higher health
care costs. Since 2013, premiums and deductibles in the non-group market have jumped
dramatically, while millions have lost their previous coverage, notwithstanding high-profile
presidential promises that they could keep it.
[8]
[9]
Bureaucracy, red tape, and paperwork still plague the financing and delivery of care, clogging
pathways to innovation, increasing costs, and frustrating individuals and families, employers
and employees, and doctors and patients alike. Indeed, the ACA’s administrative requirements
are making these long-festering problems progressively worse.
The Administration cites the law’s five-year expansion of insurance coverage: 20 million
additional enrollees. Major Medicaid expansion is arguably the law’s biggest
achievement, though persons enrolled in Medicaid often have no alternatives and have
only limited access to doctors and medical specialists. The professional literature shows that
Medicaid’s performance in care delivery is substandard.
[10]
[11]
[12]
Given the sheer magnitude of the ACA’s insurance subsidies, it is odd that exchange
enrollment is falling well short of official expectations. In 2015, the Congressional Budget
Office (CBO) reported that 9.5 million persons enrolled in the exchanges rather than the
expected 11 million; for 2016, the CBO projects 13 million exchange enrollees, a big drop
from the agency’s earlier projection of 21 million.[13] Moreover, 2014 data show that
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increased enrollment in exchanges has been accompanied by roughly equal decreases in jobbased coverage.[14]
Poor Performance
The functionality of key ACA provisions is a recurrent issue. Timothy Jost of Washington and
Lee University and Harold Pollack of the University of Chicago, prominent academic
supporters of the ACA, nonetheless acknowledge: “The ACA undertook from the beginning
an ambitious reform agenda, but some of its approaches have turned out to be ineffective,
poorly targeted, or not ambitious enough to address deeply rooted problems.”[15]
The law’s most publicized operational problems surfaced with the disastrous October 2013
rollout of healthcare.gov, the federal government’s website for enrollment in the health
insurance exchanges. It was a technical and managerial failure of mammoth proportions. The
Department of Health and Human Services (HHS) Office of Inspector General found multiple
managerial failures damaging the website launch: “Most critical were the absence of clear
leadership, which caused delays in decision-making, lack of clarity in project tasks, and the
inability of CMS [the Centers for Medicare and Medicaid Services] to recognize the
magnitude of the problems as the project deteriorated.”[16]
Technical problems can be resolved by technical fixes, and managerial messes can be cleaned
up with new management, but the ACA’s problems have multiplied well beyond the
functionality of the federal website or poor management of an admittedly complex set of
interlocking programs. Fundamentally, they are problems of legislative design, particularly in
the regulation of health insurance:Patient Protection and Affordable Care Act of 2010 Essay
An overly complex system of excessive insurance subsidies,
Health benefit mandates and rating rules that greatly increase health insurance costs, and
A flawed arrangement for protecting persons from coverage exclusions for preexisting
medical conditions.[17]
Grace-Marie Turner of the Galen Institute, a critic of the ACA, has identified 70
administrative, legislative, and judicial changes in the law, some quite large, that attempt to
compensate for its design flaws or forestall unacceptable consequences. “In short,”
observes Christopher Conover, a professor of health policy at Duke University, “the law being
implemented today is in many ways quite different than the law passed by a very temporary
super-majority of Democrats back in 2010.”
[18]
[19]
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Consider, for example, the large long-term care program: the Community Living Assistance
Services and Supports (CLASS) Act. Based on the Administration’s own initial assessment, it
was not and could not be financially viable, and Congress, with the acquiescence of the
Administration, ended it in 2012, thus precipitously erasing the anticipated collection of tens
of billions of dollars in revenues within the initial 10 years of the ACA’s implementation—
monies crucial to the Administration’s stated goal of deficit reduction.
Consider also the law’s government health insurance exchanges, heavily regulated and
federally supervised health insurance mechanisms that are markedly different in goals and
functions from market-based exchanges. Six years after the law was enacted, only 13
states are running their own exchanges—a fairly poor showing for a taxpayer cost of over $5
billion—and a number of state efforts have failed in a spectacular fashion.
[20]
[21]
There are other flawed ACA creations. More than half of the law’s nonprofit co-op health
plans, heavily financed with taxpayer-backed loans and designed to enhance competition in
the exchanges, have collapsed. Similarly, the multi-state plan program, creating a special
class of plans administered by the U.S. Office of Personnel Management (OPM), is also
performing well short of expectations.Patient Protection and Affordable Care Act of 2010 Essay
[22]
[23]
The law’s health insurance subsidy program, encompassing both premium- and cost-sharing
assistance, is mind-numbingly complex and excruciatingly difficult to administer. The amount
of an enrollee’s subsidy depends not only on the person’s eligibility and income category, but
also on changes in income over the course of the year, family size, the cost of the specific
exchange benchmark plan in the person’s county of residence, and completion of the
necessary paperwork to secure the assistance.
While low-income enrollees in the exchanges are supposed to be insulated from rising
premium costs (and many are), incorrect income reporting or flawed data collection has
resulted in 50 percent of recipients owing money back to the government. Investigating
the program, the U.S. Government Accountability Office (GAO) found data inconsistencies
among 431,000 enrollees, accounting for $1.7 billion in 2014 subsidies, as well as inadequate
protections against fraud. The program is also under congressional scrutiny for the
wrongful transmission of an estimated $750 million in taxpayer subsidies to illegal aliens.
[24]
[25]
[26]
Finally, there are the law’s unprecedented mandates. In 2014, the individual mandate forcing
Americans to buy federally approved health coverage became effective, but the seeming
reluctance of the Obama Administration to enforce it vigorously was soon evident in various
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exemptions and delays. In 2016, based on official estimates, approximately 90 percent of
an estimated 30 million uninsured would not be forced to pay the penalty because of
multiplying exemptions.Patient Protection and Affordable Care Act of 2010 Essay
[27]
[28]
Likewise, in 2014, the Administration delayed the reporting and penalty provisions of the
employer mandate as well as the politically unattractive Medicare Advantage (MA) payment
cuts. Even prominent congressional “progressives” have reversed course on the wisdom of
MA payment reductions. Sixty-one Senators and more than 300 House Members are on record
against cuts in the popular program.[29]
Detailed Control
The Patient Protection and Affordable Care Act of 2010 is arguably the largest and most
comprehensive social legislation in American history. In 908 pages of statutory text, organized
in 10 titles, its prescriptions cover a broad range of big topics:
The structure and operations of the health insurance market;
The administration of public programs (with 165 sections affecting Medicare alone);
Health care delivery reforms; and
The training and recruitment of the health care workforce.
The result: Virtually every major decision in the health care sector of the American economy
is either made or constrained, directly or indirectly, by federal officials.
Under Title I, federal officials define the content of health insurance coverage, including
required medical treatments, procedures, and preventive health care services. Federal officials
enforce permitted levels of coverage as well as the officially acceptable level of premiums.
With certain statutory or administrative exceptions, all Americans are legally required to
provide or enroll in federally approved insurance coverage or pay a tax penalty for refusing to
provide such coverage as an employer or to enroll in such coverage as an individual. Federal
officials enforce rules governing insurance rating, co-payments and deductible levels, and
allowable profit and administrative expenses. Private health insurance is “private” in name
only.[30]
The ACA has also effected a massive erosion of the states’ traditional authority over health
insurance regulation. Federal officials establish or supervise health insurance exchanges for
the purchase of health plans. In 2017, the law provides for a waiver from federal rules for
state experimentation if, and only if, the Secretary of Health and Human Services should grant
such a waiver. Even so, the scope of the ACA waiver is limited.
[31]
[32]
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Top 10 Reasons Why the ACA’s Future Is Uncertain
The ACA secures a massive centralization of power in Washington, yet this compromises the
federal government’s own efficiency and effectiveness. As Dr. Joseph Antos of the American
Enterprise Institute and his colleagues have observed:
The fundamental problem with reliance on centralized control over a sector of the economy
as complex and vast as health care is that no person or bureaucracy could possess the
requisite knowledge to properly set the dials of control to achieve the best balance of cost and
quality. Moreover, what is understood about effective medical care is changing far too rapidly
for a government bureaucracy to keep up.Patient Protection and Affordable Care Act of 2010 Essay
[

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Not surprisingly, for sound philosophical reasons that are deeply rooted in America’s rich
political culture of personal liberty, those Americans who opposed enactment of the ACA
have expressed profound aversion to government control of their health care decisions.
Beyond these practical and philosophical reasons, there is no mystery why Americans, on
everyday matters that directly concern them, continue to oppose the law. For example:
[34]
Reason #1: Despite the President’s repeated promises, rising insurance costs continue to
burden businesses and families.
At the very inception of the debate, President Obama repeatedly insisted that American
families would experience an annual of $2,500 in their health costs. During the
2009 debate, Jonathan Gruber, MIT professor of economics and an Administration adviser,
also predicted, “What we know for sure is the bill will lower the cost of buying non-group
health insurance.”
reduction [35]
[36]
From the beginning, the President’s claim of a premium decline was unsupported by the data.
During the 2009 debate on the law, the CBO initially estimated that premiums in the
individual market would increase between 10 percent and 13 percent. For the vast
majority of Americans still enrolled in the huge employment-based health insurance markets,
the Office of the Actuary at the Centers for Medicare and Medicaid Services reported in April
2010 that the health law’s new taxes on health insurance, drugs, and medical devices would
also translate into higher group insurance premiums.
[37]
[38]
In 2014, the first year of full implementation of the Title I provisions governing
health insurance, Americans enrolled in the exchanges experienced premium rate shocks.
Based on the data in the individual market over the 2013 to 2014 period, enrollees’ 2014
Rate Shock.
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premiums, reflecting the new mandates and regulations, generally increased in most states of
the Union, though increases varied:
For 27-year-olds, premiums in 11 states more than doubled;
For 50-year-olds, there was a premium increase of 50 percent or more in 13 states; and
In 14 states, premium increases were more modest: between none and 25 percent.[39]
Within the ACA exchanges, narrow network plans also flourished—an unpleasant surprise for
patients who wanted broader access to doctors and other medical professionals.[40]
In 2015, the rate of growth in premiums declined. While the average national premium
increase in the exchanges was 5.3 percent, there was wide variation among the states. In
New York and Ohio, for example, the average premium increases were 2 percent and 11
percent, respectively.Patient Protection and Affordable Care Act of 2010 Essay
[41]
For 2016, insurance companies expect “higher-than-expected” premium costs in the
exchanges. HealthPocket, a national firm comparing rates and benefits, reports that
insurers in 45 states have requested an average premium rate increase of 12 percent. The
CBO recently confirmed this general upward trend: “Insurance premiums—the payments
made to buy that coverage by enrollees or by other parties on their behalf—are high and
rising.”
[42]
[43]
[44]
Premium growth rates vary between group and non-group coverage, and the CBO is generally
conservative in its estimates. For group coverage, the CBO projects that premium growth will
accelerate over the period from 2016 to 2025, increasing by “nearly” 60 percent. For nongroup coverage in the exchanges, between 2016 and 2018, the CBO estimates that premiums
for the basic “silver” plans (the benchmark plans in the ACA exchanges) will grow about 8
percent annually on average; after 2018, they are projected to rise in line with employmentbased plans: roughly between 5 percent and 6 percent per annum on average.
[45]
[46]
Reason #2: The ACA generates big and surprising out-of-pocket costs.
Beyond premium increases, there are deductible costs. There is generally an inverse
relationship between premiums and deductibles. Choosing a low-cost premium plan in the
health insurance exchanges usually means paying much higher deductibles. For many persons,
the trade-off is perfectly reasonable, but the law imposes costly comprehensive benefit
requirements and insurance rules, so for many middle-income persons, given that there is no
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legal alternative, the choice of insurance is constrained. Urban Institute analysts, though
strongly supportive of the ACA, note the problem:
Although coverage has increased significantly thus far, fewer people than expected may sign
up in the future if they determine that they are paying premiums for plans that require
substantial amounts of cost-sharing. For many moderate-income people, particularly those in
good health, the high cost-sharing requirements may not seem worth the premiums paid to
get them.Patient Protection and Affordable Care Act of 2010 Essay
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Families USA, a prominent liberal advocacy group and also a strong supporter of the law, has
likewise reported that as a general matter, too many lower- and middle-income persons
purchasing exchange plans found the deductibles and other out-of-pocket costs discouraging
and went without care.[48]
It is a curious paradox that the ACA has generated monumental growth in high-deductible
health plans, the very type of coverage that progressives have long found unpalatable and that
are sometimes denounced as “junk” insurance. In the exchanges, as of March 2015, almost 90
percent of persons were enrolled in lower-cost silver or bronze health plans. Silver plans had
an average deductible of $2,500, and bronze plans had deductibles exceeding $5,300 for
single coverage. About half of all workers in employment-sponsored coverage, by
contrast, have an annual deductible of roughly $1,000 or more. The high-deductible
sticker shock has doubtless most affected those persons who have lost employer-based
coverage.
[49]
[50]
As with ACA plan premiums, as noted, there is a taxpayer subsidy for plan deductibles and
other out-of-pocket costs for income-eligible persons enrolled in the exchanges. These special
subsidies are available to enrollees who choose a silver-level health plan, which means
that the plan must pay 70 percent of the average enrollee’s total medical expenses for covered
benefits, with the enrollee paying the rest through deductibles and co-payments. In
comparison, the actuarial value level for a bronze plan is set at 60 percent, and the more
expensive gold and platinum plans are set at 80 percent and 90 percent, respectively.Patient Protection and Affordable Care Act of 2010 Essay
only
Under the law, a premium subsidy is available for a person with an annual income of between
100 percent ($11,770) and 400 percent ($47,080) of the federal poverty level (FPL). The costsharing subsidies covering deductibles and other out-of-pocket costs are limited to a person
with an annual income of between 100 percent and 250 percent ($29,425) of the FPL.
These subsidies reduce the deductibles and co-pays only for persons picking the silver plans,
[51]
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and depending on their income, the amount is progressively increased down the income scale.
The effect of the cost-sharing subsidy for the lowest-income persons (between 100 percent
and 150 percent of the FPL) is generous and secures for them an actuarial value of 94 percent,
which means that the choice of a silver plan would cover 94 percent of their total medical
expenses.
Apart from those who qualify for heavily subsidized premiums and co-payments, the rest of
those who purchase individual and small-group insurance have experienced much higher
premiums and much higher than expected deductibles, which in turn reflect the built-in costs
of ACA’s coverage mandates and insurance regulations. The recognition that this is a serious
problem is not confined to either conservative analysts or the Administration’s congressional
critics. Ordinary Americans also grasp the trends.
Reason #3: The ACA has reduced insurance competition.
In 2009, making his case to Congress for reform, President Obama said:
My guiding principle is, and always has been, that consumers do better when there is choice
and competition. That’s how the market works. Unfortunately, in 34 states, 75 percent of the
insurance market is controlled by five or fewer companies. In Alabama, almost 90 percent is
controlled by just one company. And without competition, the price of insurance goes up and
the quality goes down. And it makes it easier for insurance companies to treat their customers
badly—by cherry-picking the healthiest individuals and trying to drop the sickest, by
overcharging small businesses that have no leverage, and by jacking up rates.Patient Protection and Affordable Care Act of 2010 Essay
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The President is right: There is a positive correlation between increased competition and
decreased premium growth, but there is more to it than that. As the CBO has noted,
“Operating in a more competitive market gives insurers a stronger incentive to limit the
premiums that they charge and to constrain their administrative costs and profits—but in many
parts of the United States, insurance markets are not very competitive.”
[53]
[54]
In fact, Heritage Foundation research has confirmed that the ACA has not increased health
plan competition. To the contrary, the country has experienced a further concentration of the
health insurance markets. In 2013, there were 395 insurers operating in the non-group market;
in 2015, there were 307; but in 2016, there are only 287.[55]
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In 2015, at the county level where health insurance reflects local pricing, consumers in onethird of the nation’s 3,134 counties bought coverage in exchange markets that were dominated
by a monopoly (only one insurer) or duopoly (only two insurers). In fact, 58 percent of the
nation’s counties in 2015 had only three or fewer insurers participating in the exchanges.
Equally troubling, the ACA has apparently accelerated the further concentration of market
power in health care delivery, increasing corporate control over private medical practice.
[56]
[57]
Reason #4: The ACA has a negative impact on job growth.
Arguably, the employer mandate, which requires firms with 50 or more full-time workers to
offer federally approved levels of insurance coverage or pay a tax penalty, is the most
significant provision affecting business and employment. For 2016, the employer tax
penalty for each uncovered worker is from $2,160 to $3,240.
[58]
[59]
The Galen Institute has detailed various ways in which the Obama Administration has tried to
soften enforcement:Patient Protection and Affordable Care Act of 2010 Essay
On July 2, 2013, the Administration announced that it was delaying the requirement that
employers offer approved coverage and report the offering until 2015;
In 2014, the Administration announced that it would not enforce the mandate requiring
employers to offer equal coverage to all employees; and
In 2014, the Administration postponed enforcement of the employer mandate for mid-sized
employers to provide coverage until 2016.[60]
Curiously, though the employer mandate has been a staple of the progressive health policy
agenda for decades, prominent health policy analysts, such as those at the Urban Institute,
have recently expressed reservations about it and have called for its repeal.[61]
One widely anticipated impact of the employer mandate was company substitution of parttime for full-time employment. Beyond anecdotal reports, recent analytical work indicates that
the aggregate impact on the workforce has been limited. Paul Van de Water, a senior fellow
with the Center on Budget and Policy Priorities, a prominent progressive think tank, reported
in 2015 that the ACA was not stimulating a significant shift of workers from full-time to parttime work.[62]
Joseph Antos of the American Enterprise Institute and James Capretta of the Ethics and Public
Policy Center note, however, that on the basis of CBO data, the largest negative impacts on
labor participation will take place in 2017 and beyond.[63] Researchers writing in Applied
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also found little evidence of such a shift but warned that the ACA
create a future increase in part-time work with the full rollout of the employer mandate.Patient Protection and Affordable Care Act of 2010 Essay
Economic Letters could
[64]
Labor force participation has been declining for many years,
reaching a low of 62.5 percent in 2015. The CBO projects that it will remain at that level in
2016 and fall again to 62.1 percent in 2019. While many factors contribute to this decline, the
CBO has identified federal policies as contributing to the problem—most notably the ACA.
Workforce Participation.
[65]
The CBO has routinely reaffirmed its position that the ACA will have a negative impact on
America’s workforce. For example:
In June 2015, the CBO said that the law’s combination of subsidies, taxes, and Medicaid
expansions would “discourage” work.[66]
In February 2015, the CBO again told the Senate Budget Committee that the law would
reduce labor, cut aggregate compensation, and reduce federal revenues proportionately.[67]
In December 2015, the CBO estimated that the ACA will by
the equivalent of 2 million full-time workers by the year 2025.
decrease the total labor supply
[68]
In January 2016, the CBO again projected a decline in labor force participation and a negative
impact on economic growth:
CBO anticipates that several developments in federal fiscal policy under current law will
affect the economy through their impact on the labor market. The most sizable effects stem
from provisions of the Affordable Care Act (ACA). The ACA’s largest effect on the labor
market—especially as overall employment conditions improve—will come from provisions
of the act that raise effective marginal tax rates on earnings, thereby reducing how much some
people choose to work. The health insurance subsidies that the Act provides through the
expansion of Medicaid and the exchanges are phased out for people with higher income,
creating an implicit tax on some people’s additional earnings. The act also directly imposes
higher taxes on some people’s labor income. Because both effects on labor supply will grow
over the next few years, CBO projects, they will subtract from economic growth over that
period.Patient Protection and Affordable Care Act of 2010 Essay
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Reason #5: The overall health care cost curve is “bending” upward.
In another policy paradox, progressive health reformers have routinely complained that
Americans spend too much on health care but have embraced a legislative remedy that
substantially guarantees ever greater health care spending. Proposed remedies to “fix” the
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ACA’s deficiencies would obviously entail additional spending. For his part, in 2010,
President Obama said, “Every single good idea to bend the cost curve and start actually
reducing health care costs [is] in this bill.”
[70]
[71]
The President’s assertions that his policy would redirect the health cost trajectory downward
were rooted in his presidential campaign advice. In May 2007, David Blumenthal, David
Cutler, and Jeffrey Liebman, top analysts then advising the Obama campaign, circulated a
pivotal memorandum to “Interested Parties.” They claimed that, among other things, the
embryonic Obama health plan could achieve extraordinary savings, amounting to hundreds of
billions of dollars annually, from federal “investments” in information technology and reduced
overhead in health insurance, improved disease management, care coordination, clinical
effectiveness, and “pay for performance” and related “delivery reforms.” They also envisioned
big reductions in employer and employee insurance costs that would have a direct, positive
impact on ordinary Americans: “The typical family will save $2500 per year.” President
Obama, as noted, fully embraced that attractive metric—a campaign “talking point” that has
since become a toxic reminder of false expectations.
[72]
[73]
Following enactment of the ACA, some overly exuberant Administration allies quickly
credited the newly minted law with a decline in the growth of health care spending. In fact,
trend lines showed a steady decline in overall health spending growth that long predated the
law’s enactment in 2010, and that pre-ACA downturn did have a positive impact on consumer
spending. For example, for private insurance premiums in markets, premium growth
averaged 4.5 percent annually between 2005 and 2013.Patient Protection and Affordable Care Act of 2010 Essay
all
[74]
But the most compelling reason for the slowdown in the growth of health care spending had
little or nothing to do with the ACA. It was largely the result of the downturn in the economy,
particularly during the period of the Great Recession (2007–2009). Of all of the variables
contributing to the slowdown, claim Bradley Herring of Johns Hopkins University and Erin
Trish of the University of Southern California, “The most important…appears to be the Great
Recession’s effect on reduced real per capita income and the subsequent effect on reduced
health care spending, as about 41% of the recent slowdown can be explained by these
reductions in income.”[75]
In another analysis, researchers at the Kaiser Family Foundation reported that the average
annual growth in health care spending was 8.8 percent—a high rate of spending—over the
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period from 2001 to 2003, after which it declined steadily: From 2008 to 2012, it was just 4.2
percent. Kaiser researchers estimated that the economic decline was responsible for 77 percent
of the decrease in health spending growth during that period.[76]
With regard to traditional Medicare in particular, CBO analysts examined Medicare spending
over the period from 2007 to 2012 and reported that the growth rate averaged 3 percent. They
determined that the slowdown largely reflected changes in Medicare patient and provider
behavior and a variety of other factors unconnected with the sluggish economy.
Concerning Medicare and the ACA, CBO analysts later observed that “very few of the ACA’s
provisions had been implemented in any substantial way, making it difficult to attribute much
of the slowdown to the effects of specific provisions of that law.”
[77]
[78]
As for the longer-term impact of the ACA, the notion that the law would
result in a downward “bending of the cost curve” was always fanciful. Simultaneously
“bending the cost curve” downward and increasing insurance enrollment and government
subsidies would have been a neat trick for a law that created new federal entitlements and
thus became a powerful engine of massive future federal spending. In their very first report on
the impact of the law in 2010, analysts with the CMS Office of the Actuary estimated that in
10 years, national health spending would increase by an estimated $311 billion more than it
would have increased if the law had not been enacted.
Upward Bound.
[79]
[80]
Under the ACA, the trends indicate that public spending will account for a progressively
larger share of the health care economy than will private spending. In either case, a sharp
growth in health care spending, both public and private, is once again well underway.
“Although health care spending grew more slowly in the past several years than it has
historically,” the CBO reports, “over the coming decade, per-enrollee spending in federal
health programs will grow more rapidly than it has in recent years.”[81]
The latest projections are sobering. In 2014, private health insurance spending increased 5.09
percent, the largest jump since 2007, and public spending increased 6.7 percent. On a per
capita basis, based on CMS data, total spending on health insurance will rise from $7,786 in
2016 to $11,681 in 2024.Patient Protection and Affordable Care Act of 2010 Essay
[82]
[83]
The constituent elements of health spending are showing an upward surge. Over the period
from 2013 to 2015, Medicaid spending increased by 32 percent, according to the CBO; it will
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increase by 9 percent in 2016, and only then will Medicaid spending growth begin to taper off.
The ACA’s health insurance subsidies will register an average annual growth rate of 9.1
percent over the period from 2017 to 2026, the fastest rate of 10-year growth among all of the
federal government’s means-tested programs.
[84]
[85]
For 2015, the CBO reported that Medicare spending, which has an enormous influence on
America’s health care economy, increased about 7 percent, the fastest rate of growth since
2009. Overall, the CBO also reported that in 2015, the federal government spent a total of
$936 billion on health programs (for example, Medicaid, Medicare, and the ACA), a 13
percent increase over the 2014 level, outpacing Social Security spending, which totaled $882
billion.
[86]
[87]
Compounding population aging and increased per capita spending are ACA exchange
subsidies and rising Medicaid enrollment. Medicaid enrollment, based on CBO projections, is
expected to rise from 76 million in 2015 to 85 million by 2026. The Administration’s
allies in Congress and elsewhere may judge this a laudable expansion of government’s role in
health care, but it does nothing to bend the notorious “cost curve” downward.
[88]
Reason #6: The ACA is imposing major tax increases on America’s middle class.
On August 11, 2009, during the initial stages of the congressional debate, President Obama
said, “My belief is…that [health reform] should not burden people who make $250,000 a year
or less.”[89]
The President’s claim was always at best disingenuous. With a gaggle of tax increases, fees,Patient Protection and Affordable Care Act of 2010 Essay
and tax penalties, the ACA is, among other things, a huge tax bill. Over the period from 2016
to 2025, Americans will pay an estimated $832 billion in taxes, including taxes on health
insurance plans, drugs, and medical devices that will be passed on to the middle class. Not
surprisingly, Congress recently enacted delays in both the health insurance tax and the 2.3
percent excise tax on medical devices.
[90]
[91]
The so-called Cadillac tax—the 40 percent excise tax on “high value” health plans (in excess
of $10,200 for single coverage and $27,500 for family coverage)—is also in effect a tax on the
middle class. The vast majority of Americans affected by the tax, mostly those working for
large companies, have annual incomes of less than $200,000. Reacting to its unpopularity,
Congress recently enacted a two-year delay in the implementation of the Cadillac tax, which
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is now scheduled to take effect in 2020 rather than 2018. In 2020, when the provision
takes effect, CBO projects that unless employers change their plans, the tax will affect
between 5 percent and 10 percent of employer group enrollees, rising to between 15 percent
and 20 percent by 2025. Many employers will doubtless scale back their health benefit
offerings to avoid the tax.
[92]
[93]
[94]
Independent analysts confirm the tax’s widespread impact on American workers.
Kaiser Family Foundation researchers, for example, estimate that one in four employers
offering health benefits would be affected.[95]
Analysts at Johns Hopkins University estimate that with full implementation of the Cadillac
Tax, the increasingly larger number of affected employees will experience significant benefit
reductions.[96]Patient Protection and Affordable Care Act of 2010 Essay
American Enterprise Institute analysts say, “Given that there is an economic trade-off between
wages and benefits, the Cadillac tax disproportionately harms lower-income workers with
generous health benefit plans.”[97]
Even ACA taxes targeted to those who are officially designated by the government as “rich”
are designed to reach eventually deep into the ranks of the middle class. For example, the 3.8
percent Medicare payroll tax on a high-income person making $200,000 annually is not
indexed for inflation, so the tax will apply progressively to more and more persons as time
passes. The Medicare Trustees estimate that this “high income” tax would eventually reach 80
percent of all taxpayers.[98]
The tax penalty accompanying the individual mandate also
falls disproportionately on lower-income and lower-middle-income citizens. In 2014, the CBO
projected that approximately 4 million individuals would face the mandate penalty in 2016
and generate an estimated $4 billion in revenues. The CBO also estimated that 69 percent
of those persons would have incomes below 400 percent of the FPL, or below $47,080 in
today’s dollars.
The Individual Mandate Penalty.
[99]
[100]
For 2016, the individual mandate tax penalty for a single adult has increased to $695. The law
requires that the tax penalty is to be the greater of either a flat dollar amount equal to $695 per
adult plus $347.50 per child, up to a maximum of $2,085 for the family, or 2.5 percent of
family income in excess of the 2015 income tax filing thresholds ($10,300 for a single person
and $20,600 for a family).[101]
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A key question is whether persons subject to this higher tax penalty would have an incentive
to pay it and forgo coverage or whether it would encourage persons to enroll in the coverage
in the government’s health insurance exchanges. In 2015, the Kaiser Family Foundation
estimated that “out of almost 11 million uninsured people who are eligible to enroll in
marketplace coverage either with or without financial assistance, 7.1 million would pay less
for any penalty than they would to buy the least expensive insurance available to them.”[102]
Of particular interest is the response of young adults, who are disproportionately represented
among the ranks of the uninsured. For many years, there has been a downward trend in young
Americans enrolling in health insurance coverage. The number of persons under the age of 65
with private insurance has shrunk from 77 percent in 1984 to 62 percent in 2013, and this
decline, particularly in the 1990s, was attributable to premium increases.[103]
A related problem is the stability of the exchanges. As noted, in 2015, 9.5 million (as opposed
to an original CBO projection of 13 million) persons enrolled in the exchanges. For 2016,
exchange enrollments have already fallen below the CBO’s initial projections, as well as the
projections of the Administration, the Urban Institute, and the Rand Corporation. For
2016, the CBO initially estimated that 21 million persons were to be enrolled in the ACA
exchanges; the CBO has revised that number downward to just 13 million. The Obama
Administration reported that 2016 enrollments reached 12.7 million, but that number surely
will follow previous patterns of attrition, such as persons signing up but failing to pay their
premiums.
[104]
[105]
Reason #7: Medicare payment cuts will threaten seniors’ future access to care.
The law authorizes $715 billion in the form of Medicare payment reductions over the next 10
years. It is logically impossible to cut payments for Medicare services without affecting
seniors who depend on those services.Patient Protection and Affordable Care Act of 2010 Essay
[106]
On April 22, 2010, in his very first assessment of the impact of the law, CMS Chief Actuary
Richard S. Foster reported that the law’s Medicare provider payment cuts would make 15
percent of hospitals and other Medicare Part A health care providers unprofitable and
“jeopardize” seniors’ access to care. On August 10, 2010, Office of the Actuary analysts
revised these initial estimates, claiming that 25 percent of Medicare providers could face
“negative” profit margins by 2030 and 40 percent could face negative profit margins by 2050.
The analysts said that many Medicare providers would not be able to sustain such losses and
would have to withdraw from the program.
[107]
[108]
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For the past five years, the CMS Actuary, with few modifications, has reconfirmed this
negative outlook for the ACA’s impact on Medicare access. In their 2015 report, the Medicare
Trustees largely echoed the Actuary’s concerns about the impact of the payment reductions
and seniors’ access to care: “By 2040, simulations suggest that approximately half of
hospitals, 70 percent of skilled nursing facilities, and 90 percent of home health agencies
would have negative total facility margins,
for Medicare beneficiaries.”
raising the possibility of access and quality of care
issues [109]
Reason #8: The ACA threatens increased deficits and debt.
President Obama said that his health reform proposal would not add “a dime” to the federal
deficit and insisted from the inception of the debate that the final product would drive down
the deficits and be a triumph of fiscal responsibility.[110]
The CBO has continued to validate the ACA as a vehicle for deficit reduction.
In 2010, the CBO scored the bill as reducing the deficit by an estimated $124 billion in its first
10 years.
In 2012, the CBO estimated that over the period from 2013 to 2022, the law would reduce the
deficit by $109 billion.
In 2014, the CBO declared that, for a variety of reasons, it could not then determine the
budgetary impact of the law.[111]
In 2015, the CBO again assumed that the ACA would reduce the federal deficit and estimated
that repealing major provisions of the law would increase federal budget deficits by $137
billion over the period from 2016–2025.[112]
Given the ACA’s complexity, the CBO’s task is inherently difficult. CBO analysts must try to
account for a variety of unpredictable market shifts in insurance coverage that could go in any
direction. The CBO also says, for example, that per capita spending for Medicare and
Medicaid is “very difficult” to predict, noting that if per capita costs rise 1 percent faster or
slower annually than the CBOs 10-year projection, total federal outlays for both programs
would be $1 trillion higher or lower for the projected period.[113]Patient Protection and Affordable Care Act of 2010 Essay
In 2014, narrower than anticipated networks in health insurance exchange plans and higher
than expected deductibles resulted in lower plan premiums, which in turn reduced the cost of
the federal insurance subsidies and thus overall projected ACA spending. Lower than
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anticipated Medicaid enrollment following the Supreme Court’s 2012 ruling striking down of
the Medicaid mandate on the states guaranteed a reduction in Medicaid spending projections.
Lower than anticipated enrollment, premium payments and subsidies, and lower
Medicaid enrollment and spending resulted in a general lowering of the law’s total costs and
thus contributed to the CBO’s continued projections for deficit reduction.

ORDER  NOW

[114]
CBO analysts have been forthright about the uncertainty of their scoring. For example, in
2015, the CBO told the Senate Budget Committee, “If macro-economic effects had been
included in the cost estimate for the ACA that CBO provided in March 2010, the estimated
net effect of that legislation on the deficit would probably have been less favorable than that
which was shown.” More recently, addressing the potential repeal of the law, the CBO
flatly acknowledged that the impact on the deficit could go either way: “The uncertainty is
sufficiently great that repealing the ACA could in fact reduce deficits over the 2016–2025
period—or could increase deficits by a substantially larger margin than the agencies have
estimated.”
[115]
[116]
The CBO’s assessments are based on a required and conventional assumption: the continuity
of current law, in this case one that authorizes simultaneously massive increases in revenue
and unprecedented cuts in provider payments.
These are fragile assumptions, though they polish the shiny façade of
the ACA’s fiscal rectitude. In 2010, the CBO scored a legislative product that was marked by
some impressive budgetary gamesmanship: the front-loading of revenues and backloading of benefit payments over the first 10 years to guarantee a positive deficit-reducing
score.
Fragile Assumptions.
[117]
Since 2010, however, a deadly combination of budgetary pressures has threatened the ACA’s
deficit-reduction potential. The law locks in massive federal spending with unpopular taxes
and unreliable savings. For example, the substantial revenues from the long-term care
program ($86 billion from 2012–2021) disappeared with its total collapse. Other
revenues crucial to the ACA’s deficit-reduction potential are its increasingly unpopular taxes
such as the Cadillac tax, medical device tax, and health insurance tax. The survivability of
these provisions is questionable, since they generate intense bipartisan congressional
opposition. Congress delayed all three of these taxes in 2015.
[118]
Savings are also unreliable.
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Congress enacted the ACA in 2010 on the assumption that the Medicare physician payment
system, the Sustainable Growth Rate formula (SGR), would continue to restrain Medicare
spending. In 2014, when Congress, with the support of the Obama Administration, eliminated
the SGR, the lawmakers also added an estimated $141 billion in federal deficits over 10 years.Patient Protection and Affordable Care Act of 2010 Essay
[119]
In 2015, Congress defunded the Independent Payment Advisory Board (IPAB), a key ACA
mechanism designed to make recommendations for further Medicare payment reductions to
meet Medicare’s unprecedented budgetary caps.[120] The board is still not operational.
The hundreds of billions of dollars in additional savings from the ACA’s huge Medicare
payment changes and reductions are also unlikely to materialize. As early as 2010, the CBO
expressed skepticism that Medicare cuts of that magnitude were politically sustainable, and
the Medicare Actuary repeatedly declared them unrealistic.

The 2010 Affordable Care Act (ACA) included many provisions affecting the Medicare program and the 57
million seniors and people with disabilities who rely on Medicare for their health insurance coverage. Such
provisions include reductions in the growth in Medicare payments to hospitals and other health care providers
and to Medicare Advantage plans, benefit improvements, payment and delivery system reforms, higher
premiums for higher-income beneficiaries, and new revenues.
President-elect Donald Trump, Speaker of the House Paul Ryan, Health and Human Services (HHS) Secretarynominee and current House Budget Committee Chairman Tom Price, and many other Republicans in Congress
have proposed to repeal and replace the ACA, but lawmakers have taken different approaches to the
ACA’s Medicare provisions. For example, the House Budget Resolution for Fiscal Year 2017, introduced by
Chairman Price in March 2016, proposed a full repeal of the ACA. The House Republican plan, “A Better Way,”
introduced by Speaker Ryan in June 2016, proposed to repeal some, but not all, of the ACA’s Medicare
provisions.
This brief explores the implications for Medicare and beneficiaries of repealing Medicare provisions in the
ACA. The Congressional Budget Office (CBO) has estimated that full repeal of the ACA would increase
Medicare spending by $802 billion from 2016 to 2025.1 Full repeal would increase spending primarily by
restoring higher payments to health care providers and Medicare Advantage plans. The increase in Medicare
spending would likely lead to higher Medicare premiums, deductibles, and cost sharing for beneficiaries, and
accelerate the insolvency of the Medicare Part A trust fund. Policymakers will confront decisions about the
Medicare provisions in the ACA in their efforts to repeal and replace the law.
The following discussion highlights several of the key Medicare provisions in the ACA and assesses how repeal
of these provisions could affect Medicare spending and beneficiaries.2
The ACA reduced updates in Medicare payment levels to hospitals, skilled nursing facilities, hospice and home
health providers, and other health care providers. The ACA also reduced Medicare Disproportionate Share
Hospital (DSH) payments that help to compensate hospitals for providing care to low-income and uninsured
patients, with the expectation that hospitals would have fewer uninsured patients as a result of the ACA’s
coverage expansions.
What Are the Implications of Repealing the Affordable Care Act for Medicare Spending and Beneficiaries? 2
 CBO has estimated that roughly $350 billion3 of the total $802
billion in higher Medicare spending over 10 years could result from repealing ACA provisions that changed
provider payment rates in traditional Medicare. Repealing these provisions would increase payments to
providers in traditional Medicare. Additionally, some hospitals would receive higher DSH payments, if these
payments were restored to their pre-ACA levels.Patient Protection and Affordable Care Act of 2010 Essay

The Part A deductible and copayments would be expected to increase due to an increase
in Part A spending that would likely occur if payment reductions are repealed. This is because the Part A
deductible for inpatient hospital stays is indexed to updates in hospital payments, and the copayment
amounts for inpatient hospital and skilled nursing facility stays are calculated as a percentage of the Part A
deductible. Similarly, the Part B premium and deductible would be expected to increase if payments to Part
B service providers are restored. This is because Part B premiums are set to cover 25 percent of Part B
spending, and the Part B deductible is indexed to rise at the same rate as the Part B premium.
Prior to the ACA, federal payments to Medicare Advantage plans per enrollee were 14 percent higher than the
cost of covering similar beneficiaries under the traditional Medicare program, according to the Medicare
Payment Advisory Commission (MedPAC).
4 The ACA reduced payments to Medicare Advantage plans over six
years, which brought these payments closer to the average costs of care under the traditional Medicare
program. In 2016, federal payments to plans were 2 percent higher than traditional Medicare spending
(including quality-based bonus payments to plans).5

CBO has estimated that repealing the
Medicare Advantage-related provisions in the ACA would increase Medicare spending by roughly $350
billion6
(out of the $802 billion total increase) over 10 years.
 The Part B premium and
deductible would likely increase if the payment reductions for Medicare Advantage plans are repealed
because the Part B premium is set to cover 25 percent of Part B spending, and the Part B deductible is
indexed to rise at the same rate as the Part B premium.Patient Protection and Affordable Care Act of 2010 Essay

Payments that Medicare Advantage plans receive in excess of their costs to provide Part
A and Part B benefits are required to be used to provide benefits not covered by traditional Medicare, to
reduce cost sharing, premiums, or limits on out-of-pocket spending, or both. Thus, if the ACA’s reductions in
Medicare Advantage plan payments were repealed, plans could provide extra benefits to Medicare Advantage
enrollees and/or reduce enrollees’ costs.
The ACA included provisions to improve Medicare benefits by providing free coverage for some preventive
benefits, such as screenings for breast and colorectal cancer, cardiovascular disease, and diabetes, and closing
the coverage gap (or “doughnut hole”) in the Part D drug benefit by 2020. These benefit improvements
increased Medicare Part B and Part D spending.
What Are the Implications of Repealing the Affordable Care Act for Medicare Spending and Beneficiaries? 3

.


According to MedPAC, in 2013, roughly 25 percent of the 37.8 million Part D
enrollees (or around 9 million beneficiaries) had drug spending high enough to reach the coverage gap.7,8
 on average, since Part D premiums are set to cover 25.5 percent of program
costs, and reinstating the Part D coverage gap would lower Part D spending.
The ACA established new sources of revenue dedicated to the Medicare program, including a 0.9 percentage
point increase in the Medicare Part A payroll tax on earnings of higher-income workers (incomes more than
$200,000/individual and $250,000/couple), and a fee on the manufacturers and importers of branded drugs,
which has generated additional revenue for the Part B trust fund, including $3 billion in 2015 alone.9
 .

.
The ACA froze the income thresholds for the Part B income-related premium beginning at $85,000/individual
and $170,000/couple through 2019, which subjected a larger share of Medicare beneficiaries to the higher Part
B income-related premium over time.10 The law also added a new surcharge to Part D premiums for higherincome enrollees, using the same income thresholds as Part B premiums.Patient Protection and Affordable Care Act of 2010 Essay
 .

Through a new Center for Medicare & Medicaid Innovation (CMMI, or Innovation Center) within the Centers
for Medicare & Medicaid Services (CMS), the ACA directed CMS to test and implement new approaches for
Medicare to pay doctors, hospitals, and other providers to bring about changes in how providers organize and
deliver care. The ACA authorized the Secretary of Health and Human Services to expand CMMI models into
Medicare if evaluation results showed that they either reduced spending without harming the quality of care or
improved the quality of care without increasing spending. CMMI received an initial appropriation of $10
billion in 2010 for payment and delivery system reform model development and evaluation, and the ACA called
for additional appropriations of $10 billion in each decade beginning in 2020.
What Are the Implications of Repealing the Affordable Care Act for Medicare Spending and Beneficiaries? 4
The ACA also created incentives for hospitals to reduce preventable readmissions and hospital-acquired
conditions, and established new accountable care organizations (ACO) programs. Research has shown declines
in Medicare patient readmissions since the Hospital Readmission Penalty Program provisions were introduced.

On net, CBO has estimated that CMMI’s operations will generate savings of $34 billion over the
2017-2026 period, with gross savings of $45 billion over this period. These savings are attributed to the
expansion of successful payment and delivery system reform models into Medicare. In addition to
eliminating the savings generated from CMMI, Medicare spending could also increase if the incentives to
reduce preventable readmissions and hospital-acquired conditions are included in proposals to repeal and
replace the ACA.Patient Protection and Affordable Care Act of 2010 Essay
The ACA authorized a new Independent Payment Advisory Board (IPAB), a 15-member board that is required
to recommend Medicare spending reductions to Congress if projected spending growth exceeds specified target
levels, with the recommendations taking effect according to a process outlined in the ACA. To date, no
members have been appointed to the Board. Many policymakers have expressed opposition to IPAB, and there
have been several legislative attempts to eliminate it. The CMS Office of the Actuary has estimated that the
IPAB process will first be triggered in 2017, based on its most recent Medicare spending growth rate
projections.
11

CBO projects Medicare savings of $8 billion as a result of the IPAB process between 2019 and 2026.
12
Fully repealing the ACA would accelerate the projected insolvency of the Medicare Hospital Insurance (HI)
trust fund, out of which Part A benefits are paid. This would result from higher spending for Part A services due
to higher payments to Part A service providers (such as hospitals) and Medicare Advantage plans for services
provided under Part A, along with reduced revenues, if the additional 0.9 percent payroll tax on high earners is
repealed. As a result, Medicare would not be able to fulfill its obligation to pay for all Part A-covered benefits
within a shorter period of time if the ACA is repealed than if the law is retained.
Prior to enactment of the ACA in 2010, the Medicare Trustees projected that the Part A trust fund would not
have sufficient funds to pay all Part A benefits beginning in 2017. Following enactment of the law, the
insolvency date was extended. The current insolvency date is projected to be 2028. Repealing the ACA is
expected to push up the insolvency date.
What Are the Implications of Repealing the Affordable Care Act for Medicare Spending and Beneficiaries? 5
The Medicare provisions of the ACA have played an important role in strengthening Medicare’s financial status
for the future, while offsetting some of the cost of the coverage expansions of the ACA and also providing some
additional benefits to people with Medicare. Savings were achieved in part by reducing payments to providers,
such as hospitals and skilled nursing facilities. Medicare provider payment changes in the ACA were adopted in
conjunction with the ACA’s insurance coverage expansions, with the expectation that additional revenue from
newly-insured Americans would offset lower revenue from Medicare payments. In addition, Medicare savings
were achieved through lower payments to Medicare Advantage plans.Patient Protection and Affordable Care Act of 2010 Essay
Congressional action to repeal the ACA appears imminent, but it is not yet clear whether Congress will repeal
the ACA in its entirety or keep certain provisions in place. Previous Congressional proposals have taken
different approaches. For example, the House Budget Resolution for Fiscal Year 2017, introduced by Chairman
Price in March 2016, proposed a full repeal of the ACA. The House Republican plan, “A Better Way,”
introduced by Speaker Ryan in June 2016, proposed to repeal some of the ACA’s Medicare Advantage payment
changes, along with repealing IPAB and CMMI, the additional Medicare payroll tax on high earners, and
certain other tax and revenue provisions, but appears to retain other Medicare provisions, including changes to
provider payment updates and the benefit improvements.13
A majority of Americans have expressed support for some of the ACA provisions that affect Medicare, including
the elimination of out-of-pocket costs for many preventive services, closing the Part D coverage gap, and the
higher Medicare payroll tax for higher-income workers.14 Some industry stakeholders have expressed concern
about the implications of retaining the ACA’s savings provisions, yet repealing the ACA’s coverage expansions.
Aside from uncertainty about whether any of the ACA’s Medicare provisions will be retained, questions have
arisen as to what changes policymakers could advance through the legislative process known as
“reconciliation.” Policymakers are considering repealing the ACA as part of budget reconciliation legislation,
which requires only a simple majority in the Senate to pass. Senate rules (the so-called “Byrd Rule”) limit the
scope of reconciliation legislation to provisions with budgetary effects, including spending and revenues. Most
of the Medicare provisions in the ACA have budgetary effects, according to CBO, so would likely be considered
in order in the context of a reconciliation bill.
As a result of the Medicare provisions included in the ACA, Medicare spending per beneficiary has grown more
slowly than private health insurance spending; premiums and cost-sharing for many Medicare-covered
services are lower than they would have been without the ACA; new payment and delivery system reforms are
being developed and tested; and the Medicare Part A trust fund has gained additional years of solvency. Full
repeal of the Medicare provisions in the ACA would increase payments to hospitals and other health care
providers and Medicare Advantage plans, which would likely lead to higher premiums, deductibles, and cost
sharing for Medicare-covered services paid by people with Medicare. Full repeal would also reduce premiums
for higher-income beneficiaries, and reduce payroll tax contributions from beneficiaries (and other taxpayers)
with high earnings. Repealing the ACA would have uncertain effects on evolving payment and delivery system
reforms. Partial repeal of the law could also have implications for Medicare spending, the Part A trust fund
solvency date, and beneficiaries’ costs. Policymakers who seek to repeal the ACA may need to address the
implications for Medicare, beneficiaries, and other stakeholders.Patient Protection and Affordable Care Act of 2010 Essay

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