Patient Protection and Affordable Care Act
 |
| Long title |
The Patient Protection and Affordable Care Act |
| Acronyms(colloquial) |
PPACA, ACA |
| Nicknames |
Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare |
| Enacted by |
the 111th United States Congress |
| Effective |
March 23, 2010; 7 years ago
Most major provisions phased in by January 2014; remaining provisions phased in by 2020 |
| Citations |
| Public law |
111–148 |
| Statutes at Large |
124 Stat.119through 124 Stat.1025(906 pages) |
| Legislative history |
- Introduced in the Houseasthe “Service Members Home Ownership Tax Act of 2009” (H.R. 3590) byCharles Rangel (D–NY) on September 17, 2009
- Committee consideration byWays and Means
- Passed the House on October 8, 2009 (416–0)
- Passed the Senate as the “Patient Protection and Affordable Care Act” on December 24, 2009 (60–39) with amendment
- House agreed to Senate amendment on March 21, 2010 (219–212)
- Signed into law by PresidentBarack Obamaon March 23, 2010
|
| Major amendments |
Health Care and Education Reconciliation Act of 2010
Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 |
| United States Supreme Court cases |
National Federation of Independent Business v. Sebelius
Burwell v. Hobby Lobby
King v. Burwell |
The Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) and nicknamed Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by PresidentBarack Obama on March 23, 2010. Under the act, hospitals and primary physicians would transform their practices financially, technologically, and clinically to drive better health outcomes, lower costs, and improve their methods of distribution and accessibility.
The Affordable Care Act was designed to increase health insurance quality and affordability, lower the uninsured rate by expanding insurance coverage and reduce the costs of healthcare. It introduced mechanisms including mandates, subsidies and insurance exchanges.[1][2] The law requires insurers to accept all applicants, cover a specific list of conditions and charge the same rates regardless of pre-existing conditions or sex.[3]
The ACA has caused a significant reduction in the number and percentage of people without health insurance, with estimates ranging from 20-24 million additional persons covered during 2016.[4][5] Increases in overall healthcare spending have slowed since the law was implemented, including premiums for employer-based insurance plans.[6] The Congressional Budget Office reported in several studies that the ACA would reduce the budget deficit, and that repealing it would increase the deficit.[7][8]
As implementation began, first opponents, then others, and finally the president himself adopted the term “Obamacare” to refer to the ACA.[9]
The law and its implementation faced challenges in Congress and federal courts, and from some state governments, conservativeadvocacy groups, labor unions, and small business organizations. The United States Supreme Court upheld the constitutionality of the ACA’s individual mandate as an exercise of Congress’s taxing power,[10]found that states cannot be forced to participate in the ACA’s Medicaid expansion,[11][12][13] and found that the law’s subsidies to help individuals pay for health insurance are available in all states, not just in those that have set up state exchanges.[14]
Together with the Health Care and Education Reconciliation Act amendment, it represents the U.S. healthcare system‘s most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.[15][16][17]
Provisions
The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.
The ACA includes provisions to take effect between 2010 and 2020, although most took effect on January 1, 2014. Few areas of the US health care system were left untouched, making it the most sweeping health care reform since the enactment of Medicare and Medicaid in 1965.[15][16][17][19] However, some areas were more affected than others. The individual insurance market was radically overhauled, and many of the law’s regulations applied specifically to this market,[15] while the structure of Medicare, Medicaid, and the employer marketwere largely retained.[16] Most of the coverage gains were made through the expansion of Medicaid,[20] and the biggest cost savings were made in Medicare.[16] Some regulations applied to the employer market, and the law also made delivery system changes that affected most of the health care system.[16] Not all provisions took full effect. Some were made discretionary, some were deferred, and others were repealed before implementation.
Individual insurance
Guaranteed issue prohibits insurers from denying coverage to individuals due to pre-existing conditions. States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
States were required to expand Medicaid eligibility to include individuals and families with incomes up to 133% of the federal poverty level, including adults without disabilities or dependent children.[21] The law provides a 5% “income disregard”, making the effective income eligibility limit for Medicaid 138% of the poverty level.[22]
The State Children’s Health Insurance Program (CHIP) enrollment process was simplified.[21]
Dependents were permitted to remain on their parents’ insurance plan until their 26th birthday, including dependents that no longer live with their parents, are not a dependent on a parent’s tax return, are no longer a student, or are married.[23][24]
Among the groups who remained uninsured were:
- Illegal immigrants, estimated at around 8 million—or roughly a third of the 23 million projection—are ineligible for insurance subsidies and Medicaid.[25][26] They remain eligible for emergency services.
- Eligible citizens not enrolled in Medicaid.[27]
- Citizens who pay the annual penalty instead of purchasing insurance, mostly younger and single.[27]
- Citizens whose insurance coverage would cost more than 8% of household income and are exempt from the penalty.[27]
- Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states’ new insurance exchanges.[28]
Subsidies
Households with incomes between 100% and 400% of the federal poverty level were eligible to receive federal subsidies for policies purchased via an exchange.[29][30] Subsidies are provided as an advanceable, refundable tax credit[31][32] Additionally, small businesses are eligible for a tax credit provided that they enroll in the SHOP Marketplace.[33] Under the law, workers whose employers offer affordable coverage will not be eligible for subsidies via the exchanges. To be eligible the cost of employer-based health insurance must exceed 9.5% of the worker’s household income.
Subsidies (2014) for Family of 4[34][35][36][37][38]
| Income % of federal poverty level |
Premium Cap as a Share of Income |
Incomea |
Max Annual Out-of-Pocket Premium |
Premium Savingsb |
Additional Cost-Sharing Subsidy |
| 133% |
3% of income |
$31,900 |
$992 |
$10,345 |
$5,040 |
| 150% |
4% of income |
$33,075 |
$1,323 |
$9,918 |
$5,040 |
| 200% |
6.3% of income |
$44,100 |
$2,778 |
$8,366 |
$4,000 |
| 250% |
8.05% of income |
$55,125 |
$4,438 |
$6,597 |
$1,930 |
| 300% |
9.5% of income |
$66,150 |
$6,284 |
$4,628 |
$1,480 |
| 350% |
9.5% of income |
$77,175 |
$7,332 |
$3,512 |
$1,480 |
| 400% |
9.5% of income |
$88,200 |
$8,379 |
$2,395 |
$1,480 |
| a.^ Note: In 2014, the FPL was $11,800 for a single person and $24,000 for family of four.[39][40] See Subsidy Calculator for specific dollar amount.[41] b.^ DHHS and CBO estimate the average annual premium cost in 2014 would have been $11,328 for a family of 4 without the reform.[36] |
Premiums were the same for everyone of a given age, regardless of preexisting conditions. Premiums were allowed to vary by enrollee age, but those for the oldest enrollees (age 45-64 average expenses $5,542) could only be three times as large as those for adults (18-24 $1,836).[42]
Mandates
Individual
The individual mandate[43] is the requirement to buy insurance or pay a penalty for everyone not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs (such as Tricare). Also exempt were those facing a financial hardship or who were members in a recognized religious sect exempted by the Internal Revenue Service.[44]
The mandate and the limits on open enrollment[45][46] were designed to avoid the insurance death spiral in which healthy people delay insuring themselves until they get sick. In such a situation, insurers would have to raise their premiums to cover the relatively sicker and thus more expensive policies,[43][47][48] which could create a vicious cycle in which more and more people drop their coverage.[49]
The purpose of the mandate was to prevent the healthcare system from succumbing to adverse selection, which would result in high premiums for the insured and little coverage (and thus more illness and medical bankruptcy) for the uninsured.[47][50][51] Studies by the CBO, Gruber and Rand Health concluded that a mandate was required.[52][53][54] The mandate increased the size and diversity of the insured population, including more young and healthy participants to broaden the risk pool, spreading costs.[55] Experience in New Jersey and Massachusetts offered divergent outcomes.[50][53][56]
Business
Businesses that employ 50 or more people but do not offer health insurance to their full-time employees pay a tax penalty if the government has subsidized a full-time employee’s healthcare through tax deductions or other means. This is commonly known as the employer mandate.[57][58] This provision was included to encourage employers to continue providing insurance once the exchanges began operating.[59] Approximately 44% of the population was covered directly or indirectly through an employer.[60][61]
Excise taxes
Excise taxes for the Affordable Care Act raised $16.3 billion in fiscal year 2015 (17% of all excise taxes collected by the Federal Government). $11.3 billion was an excise tax placed directly on health insurers based on their market share. The ACA was going to impose a 40% “Cadillac tax” on expensive employer sponsored health insurance but that was postponed until 2018. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well.[62]
Insurance standards
Essential health benefits
The National Academy of Medicine defined the law’s “essential health benefits” as “ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care”[63][64][65][66][67][68][69] and others[70] rated Level A or B by the U.S. Preventive Services Task Force.[71] In determining what would qualify as an essential benefit, the law required that standard benefits should offer at least that of a “typical employer plan”.[68] States may require additional services.[72]
Contraceptives
One provision in the law mandates that health insurance cover “additional preventive care and screenings” for women.[73] The guidelines mandate “[a]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity”.[74] This mandate applies to all employers and educational institutions except for religious organizations.[75][76] These regulations were included on the recommendations of the Institute of Medicine.[77][78]
Risk management
ACA provided three ways to control risk for insurers in the individual and business markets: temporary reinsurance, temporary risk corridors, and permanent risk adjustment.
Risk corridor program
The risk-corridor program was a temporary risk management device defined under the PPACA section 1342[79]:1 to encourage reluctant insurers into the “new and untested” ACA insurance market during the first three years that ACA was implemented (2014-2016). For those years the Department of Health and Human Services (HHS) “would cover some of the losses for insurers whose plans performed worse than they expected. Insurers that were especially profitable, for their part, would have to return to HHS some of the money they earned on the exchanges”[80][81] According to an article in Forbes, risk corridors “had been a successful part of the Medicare prescription drug benefit, and the ACA’s risk corridors were modeled after Medicare’s Plan D.”[82] They operated on the principle that “more participation would mean more competition, which would drive down premiums and make health insurance more affordable” and “[w]hen insurers signed up to sell health plans on the exchanges, they did so with the expectation that the risk-corridor program would limit their downside losses.”[80] The risk corridors succeeded in attracting ACA insurers. The program did not pay for itself as planned with “accumulated losses” up to $8.3 billion for 2014 and 2015 alone. Authorization had to be given so that HHS could pay insurers from “general government revenues”. Congressional Republicans “railed against” the program as a ‘bailout’ for insurers. Then-Rep. Jack Kingston (R-Ga.), on the Appropriations Committee that funds the Department of Health and Human Services and the Labor Department “[slipped] in a sentence” — Section 227 — in the “massive” appropriationsConsolidated Appropriations Act, 2014 (H.R. 3547) that said that no funds in the discretionary spending bill “could be used for risk-corridor payments.” This effectively “blocked the administration from obtaining the necessary funds from other programs”[83] and placed Congress in a potential breach of contract with insurers who offered qualified health plans, under the Tucker Act[79] as it did not pay the insurers.[84][84] On February 10, 2017, in the Moda Health v the US Government, Moda, one of the insurers that struggled financially because of the elimination of the risk corridor program, won a “$214-million judgment against the federal government”. Justice Thomas C. Wheeler stated, “the Government “made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, ‘to say to [Moda], ‘The joke is on you. You shouldn’t have trusted us,’ is hardly worthy of our great government.”[85]
Temporary reinsurance
Temporary reinsurance for insurance for insurers against unexpectedly high claims was a program that ran from 2014 through 2016. It was intended to limit insurer losses.[citation needed]
Risk adjustment
Of the three risk management programs, only risk adjustment was permanent. Risk adjustment attempts to spread risk among insurers to prevent purchasers with good knowledge of their medical needs from using insurance to cover their costs (adverse selection). Plans with low actuarial risk compensate plans with high actuarial risk.[citation needed]
Other provisions
The ACA has several other provisions:
- Annual and lifetime coverage caps on essential benefits were banned.[86][87]
- Prohibits insurers from dropping policyholders when they get sick.[88]
- All health policies sold in the United States must provide an annual maximum out of pocket (MOOP) payment cap for an individual’s or family’s medical expenses (excluding premiums). After the MOOP payment cap is reached, all remaining costs must be paid by the insurer.[89]
- A partial community rating requires insurers to offer the same premium to all applicants of the same age and location without regard to gender or most pre-existing conditions (excluding tobacco use).[90][91][92] Premiums for older applicants can be no more than three times those for the youngest.[93]
- Preventive care, vaccinations and medical screenings cannot be subject to co-payments, co-insurance or deductibles.[94][95][96] Specific examples of covered services include: mammograms and colonoscopies, wellness visits, gestational diabetes screening, HPV testing, STI counseling, HIV screening and counseling, contraceptive methods, breastfeeding support/supplies and domestic violence screening and counseling.[97]
- The law established four tiers of coverage: bronze, silver, gold and platinum. All categories offer the essential health benefits. The categories vary in their division of premiums and out-of-pocket costs: bronze plans have the lowest monthly premiums and highest out-of-pocket costs, while platinum plans are the reverse.[68][98] The percentages of health care costs that plans are expected to cover through premiums (as opposed to out-of-pocket costs) are, on average: 60% (bronze), 70% (silver), 80% (gold), and 90% (platinum).[99]
- Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[88]
- Insurers must spend at least 80–85% of premium dollars on health costs; rebates must be issued to policyholders if this is violated.[100][101]
Exchanges
Established the creation of health insurance exchanges in all fifty states. The exchanges are regulated, largely online marketplaces, administered by either federal or state government, where individuals and small business can purchase private insurance plans.[102][103][104]
Setting up an exchange gives a state partial discretion on standards and prices of insurance.[105][106] For example, states approve plans for sale, and influence (through limits on and negotiations with private insurers) the prices on offer. They can impose higher or state-specific coverage requirements—including whether plans offered in the state can cover abortion.[107] States without an exchange do not have that discretion. The responsibility for operating their exchanges moves to the federal government.[105]
State waivers
From 2017 onwards, states can apply for a “waiver for state innovation” that allows them to conduct experiments that meet certain criteria.[108] To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as ACA, covers at least as many residents and does not increase the federal deficit.[109] Such states can exempt states from some of ACA’s central requirements, including the individual and employer mandates and the provision of an insurance exchange.[110] The state would receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under ACA plan, if they cannot be paid out due to the structure of the state plan.[108]
In May 2011, Vermont enacted Green Mountain Care, a state-based single-payer system for which they intended to pursue a waiver to implement.[111][112][113] In December 2014, Vermont decided not to continue due to high expected costs.[114]
Accountable Care Organizations
The Act allowed the creation of Accountable Care Organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated, high quality care to Medicare patients. ACOs were allowed to continue using a fee for service billing approach. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigating chronic disease. If they fail to do so, they are subject to penalties.[115]
Unlike Health Maintenance Organizations, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality of care goals.[115]
Others
Legislative history
President Obama signing the Patient Protection and Affordable Care Act on March 23, 2010
Background
An individual mandate coupled with subsidies for private insurance as a means for universal healthcare was considered the best way to win the support of the Senate because it had been included in prior bipartisan reform proposals. The concept goes back to at least 1989, when the conservativeHeritage Foundation proposed an individual mandate as an alternative to single-payer health care.[125] It was championed for a time by conservative economists and Republican senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of free rider problems. Specifically, because the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.[126][127][128]
President Bill Clintonproposed a healthcare reform bill in 1993 that included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations. Republican Senators proposed an alternative that would have required individuals, but not employers, to buy insurance.[127]Ultimately the Clinton plan failed amid an unprecedented barrage of negative advertising funded by politically conservative groups and the health insurance industry and due to concerns that it was overly complex.[129] Clinton negotiated a compromise with the 105th Congress to instead enact the State Children’s Health Insurance Program (SCHIP) in 1997.[130]
John Chafee
The 1993 Republican alternative, introduced by Senator John Chafee as the Health Equity and Access Reform Today Act, contained a “universal coverage” requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based ‘purchasing groups’.[131] Advocates for the 1993 bill included prominent Republicans such as Senators Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond.[132][133] Of 1993’s 43 Republican Senators, 20 supported the HEART Act.[125][134] Another Republican proposal, introduced in 1994 by Senator Don Nickles (R-OK), the Consumer Choice Health Security Act, contained an individual mandate with a penalty provision;[135] however, Nickles subsequently removed the mandate from the bill, stating he had decided “that government should not compel people to buy health insurance”.[136] At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for George H. W. Bush, remarked, “I don’t remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax.”[125]
Mitt Romney’s
Massachusetts went from 90% of its residents insured to 98%, the highest rate in the nation.
[137]
In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Governor Mitt Romney vetoed the mandate, but after Democrats overrode his veto, he signed it into law.[138] Romney’s implementation of the ‘Health Connector’ exchange and individual mandate in Massachusetts was at first lauded by Republicans. During Romney’s 2008 presidential campaign, Senator Jim DeMint praised Romney’s ability to “take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured”. Romney said of the individual mandate: “I’m proud of what we’ve done. If Massachusetts succeeds in implementing it, then that will be the model for the nation.”[139]
In 2007, a year after the Massachusetts reform, Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which featured an individual mandate and state-based, regulated insurance markets called “State Health Help Agencies”.[128][139] The bill initially attracted bipartisan support, but died in committee. Many of the sponsors and co-sponsors remained in Congress during the 2008 healthcare debate.[140]
By 2008 many Democrats were considering this approach as the basis for healthcare reform. Experts said that the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill[131] and that it was deliberately patterned after Romney’s state healthcare plan.[141]
Healthcare debate, 2008–10
Healthcare reform was a major topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, Hillary Clinton and the eventual nominee, Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton’s proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama’s proposal provided a subsidy but rejected the use of an individual mandate.[142][143]
During the general election, Obama said that fixing healthcare would be one of his top four priorities as president.[144] Obama and his opponent, Sen. John McCain, proposed health insurance reforms though they differed greatly. Senator John McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2 million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018.[145]
After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.[146][147] By July, a series of bills were approved by committees within the House of Representatives.[148] On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a healthcare reform bill. This group — in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe — met for more than 60 hours, and the principles that they discussed, in conjunction with the other committees, became the foundation of the Senate healthcare reform bill.[149][150][151]
Congressional Democrats and health policy experts like MIT economics professor Jonathan Gruber[152] and David Cutler argued that guaranteed issue would require both community rating and an individual mandate to ensure that adverse selection and/or “free riding” would not result in an insurance “death spiral”.[153] This approach was taken because the president and congressional leaders had concluded that more progressive plans, such as the (single-payer)Medicare for All act, could not obtain filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas — the same basic outline was supported by former Senate majority leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill’s drafters hoped to garner the votes necessary for passage.[154][155]
However, following the adoption of an individual mandate, Republicans came to oppose the mandate and threatened to filibuster any bills that contained it.[125] Senate minority leader Mitch McConnell, who led the Republican congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to prevent defections:[156]
It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out.[157]
Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as “unconstitutional”. Journalist Ezra Klein wrote in The New Yorker that “a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition.”[128] Reporter Michael Cooper of The New York Times wrote that: “the provision … requiring all Americans to buy health insurance has its roots in conservative thinking.”[127][134]
The reform negotiations also attracted attention from lobbyists,[158] including deals between certain lobby groups and the advocates of the law to win the support of groups that had opposed past reforms, as in 1993.[159][160] The Sunlight Foundation documented many of the reported ties between “the healthcare lobbyist complex” and politicians in both parties.[161]
During the August 2009 summer congressional recess, many members went back to their districts and held town hall meetings on the proposals. The nascent Tea Party movement organized protests and many conservative groups and individuals attended the meetings to oppose the proposed reforms.[147] Many threats were made against members of Congress over the course of the debate.[162][163]
When Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations.[164] He acknowledged the polarization of the debate, and quoted a letter from the late Senator Edward “Ted” Kennedy urging on reform: “what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”[165] On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.[147]
Senate
The Senate began work on its own proposals while the House was still working. The United States Constitution requires all revenue-related bills to originate in the House.[166] To formally comply with this requirement, the Senate used H.R. 3590, a bill regarding housing tax changes for service members.[167] It had been passed by the House as a revenue-related modification to the Internal Revenue Code. The bill became the Senate’s vehicle for its healthcare reform proposal, discarding the bill’s original content.[168] The bill ultimately incorporated elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican Senate minority vowing to filibuster, 60 votes would be necessary to pass the Senate.[169] At the start of the 111th Congress, Democrats had only 58 votes; the Senate seat in Minnesota ultimately won by Al Franken was still undergoing a recount, while Arlen Specter was still a Republican (he became a Democrat in April, 2009).
Negotiations were undertaken attempting to satisfy moderate Democrats and to bring Republican senators aboard; particular attention was given to Republicans Bennett, Enzi, Grassley and Snowe. On July 7 Franken was sworn into office, providing a potential 60th vote. On August 25 Ted Kennedy—a longtime healthcare reform advocate—died. Paul Kirk was appointed as Senator Kennedy’s temporary replacement on September 24.
After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Majority leader Harry Reid focused on satisfying centrists. The holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat Ben Nelson. Lieberman’s demand that the bill not include a public option[153][170] was met,[171] although supporters won various concessions, including allowing state-based public options such as Vermont’s Green Mountain Care.[171][172]
Senate vote by state.
Democratic yes (58)
Independent yes (2)
Republican no (39)
Republican not voting (1)
The White House and Reid addressed Nelson’s concerns[173] during a 13-hour negotiation with two concessions: a compromise on abortion, modifying the language of the bill “to give states the right to prohibit coverage of abortion within their own insurance exchanges”, which would require consumers to pay for the procedure out of pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[147][174] The latter half of the compromise was derisively termed the “Cornhusker Kickback”[175] and was repealed in the subsequent reconciliation amendment bill.
On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster. The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except Jim Bunning, who did not vote).[176] The bill was endorsed by the AMA and AARP.[177]
On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.[147][178][179] His victory had become significant because of its effects on the legislative process. The first was psychological: the symbolic importance of losing Kennedy’s traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of passing a bill.[180][181]
House
House vote by congressional district.
Democratic yes (219)
Democratic no (34)
Republican no (178)
No representative seated (4)
Brown’s election meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of StaffRahm Emanuel argued that Democrats should scale back to a less ambitious bill; House SpeakerNancy Pelosi pushed back, dismissing Emanuel’s scaled-down approach as “Kiddie Care”.[182][183]
Obama remained insistent on comprehensive reform. The news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him new evidence of the need for reform.[182][183] On February 22, he laid out a “Senate-leaning” proposal to consolidate the bills.[184] He held a meeting with both parties’ leaders on February 25. The Democrats decided that the House would pass the Senate’s bill, to avoid another Senate vote.
House Democrats had expected to be able to negotiate changes in a House-Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[181] They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.[182][185][186]
As per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations.[187][188] Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats’ demands were budgetary: “these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they’re exactly the kinds of policies that are well-suited for reconciliation.”[185]
The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their concerns, but they could not address abortion in the reconciliation bill as it would be non-budgetary. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[189] This won the support of Stupak and members of his group and assured the bill’s passage.[186][190] The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[191] The next day, Republicans introduced legislation to repeal the bill.[192] Obama signed ACA into law on March 23, 2010.[193] Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act over sixty times; no such attempt by Republicans has been successful.[194] The amendment bill, The Health Care and Education Reconciliation Act, cleared the House on March 21; the Senate passed it by reconciliation on March 25, and Obama signed it on March 30.
Impact
Coverage rate, employer market cost trends, budgetary impact, and income inequality aspects of the Affordable Care Act.
This chart illustrates several aspects of the Affordable Care Act, including number of persons covered, cost before and after subsidies, and public opinion.
Coverage
The law has caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% during the January–June 2016 period.[195] From Q4-2013 to Q1-2016, a Gallup survey found that the uninsured rate among adults declined from 17.1% to 11.0%, a decline of 6.1 percentage points.[196] In a 2016 review, Obama presented data showing that the uninsured rate had declined by 43%, from 16.0% in 2010 to 9.1% in 2015, mostly in 2014.[197] The uninsured rate dropped in every congressional district in the U.S. between 2013 and 2015.[198]
In March 2016, the CBO reported that there were approximately 27 million people without insurance in 2016, a figure they expected would range from 26-28 million through 2026. CBO also estimated the percentage of insured among all U.S. residents would remain at 90% through that period, 92-93% excluding unauthorized immigrants.[4]
Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64.[199] As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.[200]
The Congressional Budget Office reported in March 2016 that there were approximately 12 million people covered by the exchanges (10 million of whom received subsidies to help pay for insurance) and 11 million made eligible for Medicaid by the law, a subtotal of 23 million people. An additional 1 million were covered by the ACA’s “Basic Health Program,” for a total of 24 million.[4] CBO also estimated that the ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4 million for reductions in “employment-based coverage” and “non-group and other coverage.”[4] The Department of Health and Human Services (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016, a 2.4 million increase over September 2015. HHS estimated that this 20.0 million included: a) 17.7 million from the start of open enrollment in 2013-2016; and b) 2.3 million young adults aged 19–25 who initially gained insurance from 2010-2013, as they were allowed to remain on their parent’s plans until age 26. Of the 20.0 million, an estimated 6.1 million were aged 19–25.[5]
By 2017, nearly 70% of those on the exchanges could purchase insurance for less than $75/month after subsidies, which rose to offset significant pre-subsidy price increases in the exchange markets.[201] Healthcare premium cost increases in the employer market continued to moderate. For example, healthcare premiums for those covered by employers rose by 69% from 2000-2005, but only 27% from 2010 to 2015,[6] with only a 3% increase from 2015 to 2016.[202]
The ACA also helps reduce income inequality measured after taxes, due to higher taxes on the top 5% of income earners and both subsidies and Medicaid expansion for lower-income persons.[203] CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. For scale, the subsidy for the employer market, in the form of exempting from taxation those health insurance premiums paid on behalf of employees by employers, was approximately $1,700 per person in 2016, or $266 billion total in the employer market. The employer market subsidy was not changed by the law.[4]
Insurance exchanges
As of August 2016, 15 states operated their own exchanges. Other states either used the federal exchange, or operated in partnership with or supported by the federal government.[204]
Medicaid expansion
Medicaid expansion by state.[205]
Adopted the Medicaid expansion
Medicaid expansion under discussion
Not adopting Medicaid expansion
As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.[200] Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64.[199] Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they didn’t expand Medicaid under the ACA, several states rejected expanded Medicaid coverage. Over half of the national uninsured population lived in those states.[206] In a report to Congress, the Centers for Medicare and Medicaid Services (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults.[207] The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered because of states that rejected the Medicaid expansion.[208]
States that rejected the Medicaid expansion could maintain their Medicaid eligibility thresholds, which in many states were significantly below 133% of the poverty line.[209]Many states did not make Medicaid available to childless adults at any income level.[210] Because subsidies on exchange insurance plans were not available to those below the poverty line, such individuals had no new options.[211][212] For example, in Kansas, where only able-bodied adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance. Absent children, able-bodied adults were not eligible for Medicaid in Kansas.[206]
Studies of the impact of state decisions to reject the Medicaid expansion calculated that up to 6.4 million people could fall into this status.[213] The federal government initially paid for 100% of the expansion (through 2016). The subsidy tapered to 90% by 2020 and continued to shrink thereafter.[214] Several states argued that they could not afford their 10% contribution.[214][215] Studies suggested that rejecting the expansion would cost more than expanding Medicaid due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,[216]
A 2016 study led by Harvard University health economics professor Benjamin Sommers found that residents of Kentucky and Arkansas, which both accepted the Medicaid expansion, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills than before the expansion. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period.[217] Kentucky opted for increased managed care, while Arkansas subsidized private insurance. The new Arkansas and Kentucky governors have proposed reducing or modifying their programs. Between 2013 and 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas. Specific improvements included additional primary and preventive care, fewer emergency departments visits, reported higher quality care, improved health, improved drug affordability, reduced out-of-pocket spending and increased outpatient visits, increased diabetes screening, glucose testing among diabetes patients and regular care for chronic conditions.[218]
A 2016 DHHS study found that states that expanded Medicaid had lower premiums on exchange policies, because they had fewer low-income enrollees, whose health on is worse than that of those with higher income.[219]
Healthcare insurance costs
The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance, based on income levels. Higher income consumers receive lower subsidies. While pre-subsidy prices rose considerably from 2016 to 2017, so did the subsidies, to reduce the after-subsidy cost to the consumer. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas.[221] However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reported that for the second-lowest cost “Silver plan” (a plan often selected and used as the benchmark for determining financial assistance), a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the subsidy/tax credit, despite large increases in the pre-subsidy price. This was consistent nationally. In other words, the subsidies increased along with the pre-subsidy price, fully offsetting the price increases.[222]
Healthcare premium cost increases in the employer market continued to moderate after the implementation of the law. For example, healthcare premiums for those covered by employers rose by 69% from 2000-2005, but only 27% from 2010 to 2015,[6] with only a 3% increase from 2015 to 2016.[202] From 2008-2010 (prior to Obamacare) health insurance premiums rose by an average of 10% per year.[223]
Several studies found that the financial crisis and accompanying recession could not account for the entirety of the slowdown and that structural changes likely share at least partial credit.[224][225][226][227] A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation.[228] Paul Krawzak claimed that even if cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly the growth of the population on Medicare.[229]
In a 2016 review of the ACA published in JAMA, Barack Obama himself wrote that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.[230]
Effect on deductibles and co-payments
While health insurance premium costs have moderated, some of this is because of insurance policies that have a higher deductible, co-payments and out-of-pocket maximums that shift costs from insurers to patients. In addition, many employees are choosing to combine a health savings account with higher deductible plans, making the impact of the ACA difficult to determine precisely.
For those who obtain their insurance through their employer (“group market”), a 2016 survey found that:
- Deductibles grew by 63% from 2011 to 2016, while premiums increased 19% and worker earnings grew by 11%.
- In 2016, 4 in 5 workers had an insurance deductible, which averaged $1,478. For firms with less than 200 employees, the deductible averaged $2,069.
- The percentage of workers with a deductible of at least $1,000 grew from 10% in 2006 to 51% in 2016. The 2016 figure drops to 38% after taking employer contributions into account.[231]
For the “non-group” market, of which two-thirds are covered by the ACA exchanges, a survey of 2015 data found that:
- 49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
- Many marketplace enrollees qualify for cost-sharing subsidies that reduce their net deductible.
- While about 75% of enrollees were “very satisfied” or “somewhat satisfied” with their choice of doctors and hospitals, only 50% had such satisfaction with their annual deductible.
- While 52% of those covered by the ACA exchanges felt “well protected” by their insurance, in the group market 63% felt that way.[232]
Health outcomes
Insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.[233]City University public health professors David Himmelstein and Steffie Woolhandler wrote in January 2017 that a rollback of the ACA’s Medicaid expansion alone would cause an estimated 43,956 deaths annually.[234]
Federal deficit
CBO estimates of revenue and impact on deficit
The CBO reported in several studies that the ACA would reduce the deficit, and that repealing it would increase the deficit.[7][8][235][236] The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:[8][237] it calculated the law would result in $604 billion in total outlays offset by $813 billion in total receipts, resulting in a $210 billion net deficit reduction.[8] The CBO separately predicted that while most of the spending provisions do not begin until 2014,[238][239] revenue would exceed spending in those subsequent years.[240] The CBO claimed that the bill would “substantially reduce the growth of Medicare’s payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs”[241]—ultimately extending the solvency of the Medicare trust fund by 8 years.[242]
This estimate was made prior to the Supreme Court’s ruling that enabled states to opt out of the Medicaid expansion, thereby forgoing the related federal funding. The CBO and JCT subsequently updated the budget projection, estimating the impact of the ruling would reduce the cost estimate of the insurance coverage provisions by $84 billion.[243][244][245]
The CBO in June 2015 forecasted that repeal of ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic feedback effects. The CBO also forecasted that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2015, mainly by boosting the supply of labor.[7]
Major new sources of increased tax receipts include:[95] higher Medicare taxes; annual fees on insurance providers; fees on the healthcare industry such as manufacturers and importers of brand-name pharmaceutical drugs and certain medical devices; limits on tax deductions of medical expenses and flexible spending accounts; a 40% excise tax on plans with annual insurance premiums in excess of $10,200 for an individual or $27,500 for a family; revenue from mandate penalty payments; a 10% federal sales tax on indoor tanning services. Predicted spending reductions included a reduction in Medicare reimbursements to insurers and drug companies for private Medicare Advantage policies that the Government Accountability Office and Medicare Payment Advisory Commission found to be excessively costly relative to government Medicare;[246][247] and reductions in Medicare reimbursements to hospitals that failed standards of efficiency and care.[246]
Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion.[241][248] CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that “a wide range of changes could occur”.[249]
Opinions on CBO projections
The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019.[250][251][252] However, the so-called “doc fix” is a separate issue that would have existed whether or not ACA became law – omitting its cost from ACA was no different from omitting the cost of other tax cuts.[253][254][255]
Uwe Reinhardt, a Princeton health economist, wrote. “The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation”, but went on to say “But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003.”[256]Douglas Holtz-Eakin, CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain‘s 2008 presidential campaign, alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.[257]
Scheiber and Cohn rejected critical assessments of the law’s deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted that for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive healthcare, and that the CBO had a track record of overestimating costs and underestimating savings of health legislation;[258][259] stating, “innovations in the delivery of medical care, like greater use of electronic medical records[260] and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses… But the CBO would not consider such savings in its calculations, because the innovations hadn’t really been tried on such large scale or in concert with one another—and that meant there wasn’t much hard data to prove the savings would materialize.”[258]
In 2010 David Walker, former U.S. Comptroller General then working for The Peter G. Peterson Foundation, stated that the CBO estimates are not likely to be accurate, because they were based on the assumption that the law would not change.[261] The Center on Budget and Policy Priorities objected that Congress had a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings, although not the payment reductions addressed by the annual “doc fix”.[262][263]
Economic consequences
CBO estimated in June 2015 that repealing the ACA would:
- Decrease aggregate demand (GDP) in the short-term, as low-income persons who tend to spend a large fraction of their additional resources would have fewer resources (e.g., ACA subsidies would be eliminated). This effect would be offset in the long-run by the labor supply factors below.
- Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021-2025 period. CBO cited the ACA’s expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing the ACA would remove those disincentives, encouraging workers to supply more hours of labor.
- Increase the total number of hours worked by about 1.5% over the 2021-2025 period.
- Remove the higher tax rates on capital income, thereby encouraging additional investment, raising the capital stock and output in the long-run.[7]
In 2015 the Center for Economic and Policy Research found no evidence that companies were reducing worker hours to avoid ACA requirements[264] for employees working over 30 hours per week.[265]
The CBO estimated that the ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Cohn, citing CBO’s projections, claimed that ACA’s primary employment effect was to alleviate job lock: “People who are only working because they desperately need employer-sponsored health insurance will no longer do so.”[266] He concluded that the “reform’s only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire”, because they have health insurance outside of their jobs.[267]
Employer mandate and part-time work
The employer mandate requires employers meeting certain criteria to provide health insurance to their workers. The mandate applies to employers with more than 50 employees that do not offer health insurance to their full-time workers.[268] Critics claimed that the mandate created a perverse incentive for business to keep their full-time headcount below 50 and to hire part-time workers instead.[269][270] Between March 2010 and 2014 the number of part-time jobs declined by 230,000, while the number of full-time jobs increased by 2 million.[271][272] In the public sector full-time jobs turned into part-time jobs much more than in the private sector.[271][273] A 2016 study found only limited evidence that ACA had increased part-time employment.[274]
Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees,[275][unreliable source?][276][unreliable source?] to reflect the 30-hour-or-more definition for full-time worker.[268] As of yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).[270] Trends in working hours[277] and the effects of the Great Recession correlate with part-time working hour patterns.[278][279] The impact of this provision may have been offset by other factors, including that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and the lower training and administration costs of a smaller full-time workforce over a larger part-time work force.[270][277][280] Relatively few firms employ over 50 employees[270] and more than 90% of them offered insurance.[281] Workers without employer insurance could purchase insurance on the exchanges.[282]
Most policy analysts (on both right and left) were critical of the employer mandate provision.[269][281] They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful;[283][284] that the raised marginal cost of the 50th worker for businesses could limit companies’ growth;[285] that the costs of reporting and administration were not worth the costs of maintaining employer plans;[283][284] and noted that the employer mandate was not essential to maintain adequate risk pools.[286][287] The effects of the provision generated vocal opposition from business interests and some unions not granted exemptions.[284][288]
A 2013/4 survey by the National Association for Business Economics found that about 75 percent of those surveyed said ACA hadn’t influenced their planning or expectations for 2014, and 85 percent said the law wouldn’t prompt a change in their hiring practices. Some 21 percent of 64 businesses surveyed said that the act would have a harmful effect and 5 percent said it would be beneficial.[289]
Hospitals
From the start of 2010 to November 2014, 43 hospitals in rural areas closed. Critics claimed that the new law caused these hospitals to close. Many of these rural hospitals were built using funds from the 1946 Hill–Burton Act, to increase access to medical care in rural areas. Some of these hospitals reopened as other medical facilities, but only a small number operated emergency rooms (ER) or urgent care centers.[290]
Between January 2010 and 2015, a quarter of emergency room doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed that they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured patients.[291]
Insurers claimed that because they have access to and collect patient data that allow evaluations of interventions, they are essential to ACO success. Large insurers formed their own ACOs. Many hospitals merged and purchased physician practices. The increased market share gave them more leverage in negotiations with insurers over costs and reduced patient care options.[115]
Public opinion
Prior to the law’s passage, polling indicated the public’s views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Polling statistics showed a general negative opinion of the law; with those in favor at approximately 40% and those against at 51%, as of October 2013.[292][293] About 29% of whites approve of the law, compared with 61% of Hispanics and 91% of African Americans.[294]Opinions were divided by age of the person at the law’s inception, with a solid majority of seniors opposing the bill and a solid majority of those younger than forty years old in favor.[295]
Congressional Democrats celebrating the 6th anniversary of the Affordable Care Act in March 2016 on the steps of the U.S. Capitol.
Specific elements were popular across the political spectrum, while others, such as the mandate to purchase insurance, were widely disliked. In a 2012 poll 44% supported the law, with 56% against. By party affiliation, 75% of Democrats, 27% of Independents and 14% of Republicans favored the law overall. 82% favored banning insurance companies from denying coverage to people with pre-existing conditions, 61% favored allowing children to stay on their parents’ insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.[296] Other polls showed additional provisions receiving majority support, including the creation of insurance exchanges, pooling small businesses and the uninsured with other consumers so that more people can take advantage of large group pricing benefits and providing subsidies to individuals and families to make health insurance more affordable.[297][298]
In a 2010 poll, 62% of respondents said they thought ACA would “increase the amount of money they personally spend on health care”, 56% said the bill “gives the government too much involvement in health care”, and 19% said they thought they and their families would be better off with the legislation.[299] Other polls found that people were concerned that the law would cost more than projected and would not do enough to control costs.[300]
Some opponents believed that the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.[296] In June 2013, a majority of the public (52–34%) indicated a desire for “Congress to implement or tinker with the law rather than repeal it”.[301] After the Supreme Court upheld the individual mandate, a 2012 poll held that “most Americans (56%) want to see critics of President Obama’s health care law drop efforts to block it and move on to other national issues”.[302]A 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA vs. 38.3% who had a favorable view (of more than 5,500 individuals).[303]
A 2014 poll reported that 26% of Americans support ACA.[304] Another held that 8% of respondents say that the Affordable Care Act “is working well the way it is”.[305] In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%, i.e., 65% wanted to leave ACA alone or improve upon it.[306]
In 2015, a CBS News / New York Times poll reported that 47% of Americans approved the health care law. This was the first time that a major poll indicated that more respondents approved ACA than disapproved of it.[307] The recurring Kaiser Health Tracking Poll from December 2016 reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.[308]
Separate polls from Fox News and NBC/WSJ both taken during January 2017 indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who opposed it in the past (many prefer a “Medicare for All” approach) have shifted their positions since the ACA is under threat of repeal.[309]
A January 2017 Morning Consult poll showed that 35% of respondents either believed that Obamacare and the Affordable Care Act were different or did not know.[310] Approximately 45% were unsure whether the repeal of Obamacare also meant the repeal of the Affordable Care Act.[310] 39% did not know that “many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted,” with Democrats far more likely (79%) to know that fact than Republicans (47%).[310]
A 2017 study found that personal experience with public health insurance programs leads to greater support for the Affordable Care Act, and the effects appear to be most pronounced among Republicans and low-information voters.[311]
Political aspects
“Obamacare”
The term “Obamacare” was originally coined by opponents as a pejorative. The term emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott used it in a health industry journal, writing “We will soon see a ‘Giuliani-care’ and ‘Obama-care’ to go along with ‘McCain-care’, ‘Edwards-care’, and a totally revamped and remodeled ‘Hillary-care‘ from the 1990s”.[9][312] According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate’s proposal for expanding coverage for the uninsured.[313] It first appeared in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said, “In my state, I worked on healthcare for some time. We had half a million people without insurance, and I said, ‘How can we get those people insured without raising taxes and without having government take over healthcare?’ And let me tell you, if we don’t do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it’ll be government-managed care. It’ll be what’s known as Hillarycare or Barack Obamacare, or whatever you want to call it.”[9]
By mid-2012, Obamacare had become the colloquial term used by both supporters and opponents. In contrast, the use of “Patient Protection and Affordable Care Act” or “Affordable Care Act” became limited to more formal and official use.[313] Use of the term in a positive sense was suggested by Democrat John Conyers.[314] Obama endorsed the nickname, saying, “I have no problem with people saying Obama cares. I do care.”[315]
In March 2012, the Obama reelection campaign embraced the term “Obamacare”, urging Obama’s supporters to post Twitter messages that begin, “I like #Obamacare because…”.[316]
In October 2013 the Associated Press and NPR began cutting back on use of the term.[317] Stuart Seidel, NPR’s managing editor, said that the term “seems to be straddling somewhere between being a politically-charged term and an accepted part of the vernacular”.[318]
Common misconceptions
“Death panels”
On August 7, 2009, Sarah Palin pioneered the term “death panels” to describe groups that would decide whether sick patients were “worthy” of medical care.[319] “Death panel” referred to two claims about early drafts.
One was that under the law, seniors could be denied care due to their age[320] and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an Independent Payment Advisory Board (IPAB).[321] IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when the statutory levels set for Medicare were exceeded within any given 3-year period. In fact, the Board was prohibited from recommending changes that would reduce payments to certain providers before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.[322][323]
The other related issue concerned advance-care planning consultation: a section of the House reform proposal would have reimbursed physicians for providing patient-requested consultations for Medicare recipients on end-of-life health planning (which is covered by many private plans), enabling patients to specify, on request, the kind of care they wished to receive.[324] The provision was not included in ACA.[325]
In 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and 30% believed it was true, backed by three contemporaneous polls.[326] A poll in August 2012 found that 39% of Americans believed the claim.[327] The allegation was named PolitiFact‘s “Lie of the Year”,[319][328] one of FactCheck.org‘s “whoppers”[329][330] and the most outrageous term by the American Dialect Society.[331]AARP described such rumors as “rife with gross—and even cruel—distortions”.[332]
Members of Congress
ACA requires members of Congress and their staffs to obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the insurance offered to federal employees (the Federal Employees Health Benefits Program).[333][334][335][336][337]
Illegal immigrants
ACA does not provide benefits to illegal immigrants.[338] It explicitly denies insurance subsidies to “unauthorized (illegal) aliens”.[25][26][339]
Exchange “death spiral”
One argument against the ACA is that the insurers are leaving the marketplaces, as they cannot profitably cover the available pool of customers, which contains too many unhealthy participants relative to healthy participants. A scenario where prices rise, due to an unfavorable mix of customers from the insurer’s perspective, resulting in fewer customers and fewer insurers in the marketplace, further raising prices, has been called a “Death Spiral.”[340]During 2017, the median number of insurers offering plans on the ACA exchanges in each state was 3.0, meaning half the states had more and half had fewer insurers. There were five states with one insurer in 2017; 13 states with two; 11 states with three; and the remainder had four insurers or more. Wisconsin had the most, with 15 insurers in the marketplace. The median number of insurers was 4.0 in 2016, 5.0 in 2015, and 4.0 in 2014.[341]
Further, the CBO reported in January 2017 that it expected enrollment in the exchanges to rise from 10 million during 2017 to 13 million by 2027, assuming laws in place at the end of the Obama administration were continued.[342] Following a 2015 CBO report that reached a similar conclusion, Paul Krugman wrote: “But the truth is that this report is much, much closer to what supporters of reform have said than it is to the scare stories of the critics–no death spirals, no job-killing, major gains in coverage at relatively low cost.”[343]
Opposition
Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions,[344][345]conservative advocacy groups,[346][347] Republicans, small business organizations and the Tea Party movement.[348] These groups claimed that the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit.[349] Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods.[350][351] President Donald Trump has repeatedly promised to “repeal and replace” it.[352][353]
As of 2013 unions that expressed concerns about ACA included the AFL-CIO,[354] which called ACA “highly disruptive” to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, whose leaders sent a letter to Reid and Pelosi arguing, ” ACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class.”[345] In January 2014, Terry O’Sullivan, president of the Laborers’ International Union of North America (LIUNA) and D. Taylor, president of Unite Here sent a letter to Reid and Pelosi stating, “ACA, as implemented, undermines fair marketplace competition in the health care industry.”[344]
In October 2016, Mark Dayton, the governor of Minnesota and a member of the Minnesota Democratic–Farmer–Labor Party, said that the ACA had “many good features” but that it was “no longer affordable for increasing numbers of people” and called on the Minnesota legislature to provide emergency relief to policyholders.[355] Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.[356]
Legal challenges
National Federation of Independent Business v. Sebelius
Opponents challenged ACA’s constitutionality in multiple lawsuits on multiple grounds.[357][358][not in citation given] In National Federation of Independent Business v. Sebelius, the Supreme Court ruled on a 5–4 vote that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.
The Court further determined that states could not be forced to participate in the Medicaid expansion. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.[359]
Contraception mandate
In March 2012 the Roman Catholic Church, while supportive of ACA’s objectives, voiced concern through the United States Conference of Catholic Bishops that aspects of the mandate covering contraception and sterilization and HHS‘s narrow definition of a religious organization violated the First Amendment right to free exercise of religion and conscience. Various lawsuits addressed these concerns.[360][361]
On June 25, 2015, the U.S. Supreme Court ruled 6–3 that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.[362]
House v. Burwell
In United States House of Representatives v. Burwell the House sued the administration alleging that the money for premium subsidy payments to insurers had not been appropriated, as required for any federal government spending. The Obamacare subsidy that helps customers pay premiums was not part of the suit. Without the cost-sharing subsidies, the government estimated that premiums would increase by 20 percent to 30 percent for silver plans.[363]
Non-cooperation
Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements of ACA over which they had discretion.[364][365] For example, Missouri declined to expand Medicaid or establish a health insurance marketplace engaging in active non-cooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law.[366] Other Republican politicians discouraged efforts to advertise the benefits of the law. Some conservative political groups launched ad campaigns to discourage enrollment.[367][368]
Repeal efforts
ACA was the subject of unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives Steve King (R-IA) and Michele Bachmann (R-MN) introduced bills in the House to repeal ACA the day after it was signed, as did Senator Jim DeMint (R-SC) in the Senate.[369] In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill titled “Repealing the Job-Killing Health Care Law Act” (H.R. 2), which the House passed 245–189.[370] All Republicans and 3 Democrats voted for repeal.[371] House Democrats proposed an amendment that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program; Republicans voted down the measure.[372] In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down.[373] President Obama had stated that he would have vetoed the bill even if it had passed both chambers of Congress.[374]
2017 House Budget
Following the 2012 Supreme Court ruling upholding ACA as constitutional, Republicans held another vote to repeal the law on July 11;[375] the House of Representatives voted with all 244 Republicans and 5 Democrats in favor of repeal, which marked the 33rd, partial or whole, repeal attempt.[376][377] On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.[378]
2013 federal government shutdown
Strong partisan disagreement in Congress prevented adjustments to the Act’s provisions.[379] However, at least one change, a proposed repeal of a tax on medical devices, has received bipartisan support.[380] Some Congressional Republicans argued against improvements to the law on the grounds they would weaken the arguments for repeal.[284][381]
Republicans attempted to defund its implementation,[365][382] and in October 2013, House Republicans refused to fund the federal government unless accompanied with a delay in ACA implementation, after the President unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership stated the Senate would only pass a “clean” funding bill without any restrictions on ACA. The government shutdown began on October 1.[383][384][385] Senate Republicans threatened to block appointments to relevant agencies, such as the Independent Payment Advisory Board[386] and Centers for Medicare and Medicaid Services.[387][388]
2017 repeal effort
During a midnight congressional session starting January 11, 2017, the Senate of the 115th Congress of the United States voted to approve a “budget blueprint” which would allow Republicans to repeal parts of the law “without threat of a Democraticfilibuster.”[389][390] The plan, which passed 51-48 is a budget blueprint named by Senate Republicans the “Obamacare ‘repeal resolution.'”[391] Democrats opposing the resolution staged a protest during the vote.[392]
House Republicans announced their replacement for the ACA, the American Health Care Act, on March 6, 2017.[393] On March 24, 2017 the effort, led by Paul Ryan and Donald Trump, to repeal and replace the ACA failed amid a revolt among Republican representatives.[394]
Implementation history
Once the law was signed, provisions began taking effect, in a process that continued for years. Some provisions never took effect, while others were deferred for various periods.
Existing individual health plans
Plans purchased after the date of enactment, March 23, 2010, or old plans that changed in specified ways would eventually have to be replaced by ACA-compliant plans.[citation needed]
At various times during and after the ACA debate, Obama stated that “if you like your health care plan, you’ll be able to keep your health care plan”.[395][396] However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,[397] and several million more risked seeing their current plans cancelled.[398][399][400]
Obama’s previous unambiguous assurance that consumers’ could keep their own plans became a focal point for critics, who challenged his truthfulness.[401][402] On November 7, 2013, President Obama stated: “I am sorry that [people losing their plans] are finding themselves in this situation based on assurances they got from me.”[403] Various bills were introduced in Congress to allow people to keep their plans.[404]
In the fall of 2013, the Obama Administration announced a transitional relief program that would let states and carriers allow non-compliant individual and small group policies to renew at the end of 2013. In March 2014, HHS allowed renewals as late as October 1, 2016. In February 2016, these plans were allowed to renew up until October 1, 2017, but with a termination date no later than December 31, 2017.[citation needed]
2010
In June small business tax credits took effect. For certain small businesses, the credits reached up to 35% of premiums. At the same time uninsured people with pre-existing conditions could access the federal high-risk pool. Also, participating employment-based plans could obtain reimbursement for a portion of the cost of providing health insurance to early retirees.[405]
In July the Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those that had been denied coverage by private insurance companies because of a pre-existing condition. Despite estimates of up to 700,000 enrollees, at a cost of approximately $13,000/enrollee, only 56,257 enrolled at a $28,994 cost per enrollee.[405]
2011
As of September 23, 2010, pre-existing conditions could no longer be denied coverage for children’s policies. HHS interpreted this rule as a mandate for “guaranteed issue“, requiring insurers to issue policies to such children.[citation needed] By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement.[406]
The average beneficiary in the prior coverage gap would have spent $1,504 in 2011 on prescriptions. Such recipients saved an average $603. The 50 percent discount on brand name drugs provided $581 and the increased Medicare share of generic drug costs provided the balance. Beneficiaries numbered 2 million[407]
2012
In National Federation of Independent Business v. Sebelius decided on June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional when the associated penalties were construed as a tax. The decision allowed states to opt out of the Medicaid expansion. Several did so,[408] although some later accepted the expansion.[409]
2013
In January 2013 the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold. This was estimated to leave 2–4 million Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies.[410][411]
A June 2013 study found that the MLR provision had saved individual insurance consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%.[412] The bulk of the savings were in reduced premiums, but some came from MLR rebates.
On July 2, 2013, the Obama Administration announced that it would delay the implementation of the employer mandate until 2015.[281][413][414]
The Community Living Assistance Services and Supports Act (or CLASS Act) was enacted as Title VIII of Obamacare. It would have created a voluntary and public long-term care insurance option for employees.[121][123] In October 2011 the administration announced it was unworkable and would be dropped.[415] The CLASS Act was repealed January 1, 2013.[416]
The launch for both the state and federal exchanges was troubled due to management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered endless problems.[417] Operations stabilized in 2014, although not all planned features were complete.[418][419]
CMS reported in 2013 that, while costs per capita continued to rise, the rate of increase in annual healthcare costs had fallen since 2002. Per capita cost increases averaged 5.4% annually between 2000 and 2013. Costs relative to GDP, which had been rising, had stagnated since 2009.[420] Several studies attempted to explain the reductions. Reasons included:
- Higher unemployment due to the 2008-2010 recession, which limited the ability of consumers to purchase healthcare;
- Out-of-pocket costs rose, reducing demand for healthcare services.[421] The proportion of workers with employer-sponsored health insurance requiring a deductible climbed to about three-quarters in 2012 from about half in 2006.[224]
- ACA changes[224] that aim to shift the healthcare system from paying-for-quantity to paying-for-quality. Some changes occurred due to healthcare providers acting in anticipation of future implementation of reforms.[120][225]
2014
On July 30, 2014, the Government Accountability Office released a non-partisan study that concluded that the administration did not provide “effective planning or oversight practices” in developing the website.[422]
In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.[423] In Wheaton College vs Burwell the Court issued an injunction allowing the evangelical college and other religiously affiliated nonprofit groups to completely ignore the contraceptive mandate.[424]
A study found that average premiums for the second-cheapest silver plan were 10-21% less than average individual market premiums in 2013, while covering many more conditions. Credit for the reduced premiums was attributed to increased competition stimulated by the larger market, greater authority to review premium increases, the MLR and risk corridors.[citation needed]
Many of the initial plans featured narrow networks of doctors and hospitals.[425][not in citation given]
A 2016 analysis found that health care spending by the middle class was 8.9% of household spending in 2014.[426]
2015
By the beginning of the year, 11.7 million had signed up (ex-Medicaid).[427] On December 31, 2015, about 8.8 million consumers had stayed in the program. Some 84 percent, or about 7.4 million, were subsidized.[428]
Bronze plans were the second most popular in 2015, making up 22% of marketplace plan selections. Silver plans were the most popular, accounting for 67% of marketplace selections. Gold plans were 7%. Platinum plans accounted for 3%. On average across the four metal tiers, premiums were up 20% for HMOs and 18% for EPOs. Premiums for POS plans were up 15% from 2015 to 2016, while PPO premiums were up just 8%.[citation needed]
A 2015 study found 14% of privately insured consumers received a medical bill in the past two years from an out-of-network provider in the context of an overall in-network treatment event. Such out-of-network care is not subject to the lower negotiated rates of in-network care, increasing out-of-pocket costs. Another 2015 study found that the average out-of-network charges for the majority of 97 medical procedures examined “were 300% or higher compared to the corresponding Medicare fees” for those services.[citation needed]
Some 47% of the 2015 ACA plans sold on the Healthcare.gov exchange lacked standard out-of-network coverage. Enrollees in such plans, typically received no coverage for out-of-network costs (except for emergencies or with prior authorization). A 2016 study on Healthcare.gov health plans found a 24 percent increase in the percentage of ACA plans that lacked standard out-of-network coverage.[citation needed]
The December spending bill delayed the onset of the “Cadillac tax” on expensive insurance plans by two years, until 2020.[429]
The average price of non-generic drugs rose 16.2% in 2015 and 98.2% since 2011.[426]
2016
As of March 2016 11.1 million people had purchased exchange plans,[citation needed] while an estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults.[207] 11.1 million were still covered, a decline of nearly 13 percent.[430] 6.1 million uninsured 19-25 year olds gained coverage.[431]
Employers
A survey of New York businesses found an increase of 8.5 percent in health care costs, less than the prior year’s survey had expected. A 10 percent increase was expected for 2017. Factors included increased premiums, higher drug costs, ACA and aging workers. Some firms lowered costs by increasing cost-sharing (for higher employee contributions, deductibles and co-payments). 60% planned to further increase cost-sharing. Coverage and benefits were not expected to change. Approximately one fifth said ACA had pushed them to reduce their workforce. A larger number said they were raising prices.[432]
Insurers
The five major national insurers expected to lose money on ACA policies in 2016.[433] UnitedHealth withdrew from the Georgia and Arkansas exchanges for 2017, citing heavy losses.[204] Humana exited other markets, leaving it operating in 156 counties in 11 states for 2017.[434] 225 counties across the country had access to only a single ACA insurer. A study released in May estimated that 664 counties would have one insurer in 2017.[435][not in citation given]
Aetna cancelled planned expansion of its offerings and following an expected $300 million loss in 2016 and then withdrew from 11 of its 15 states.[436] In August 2016 Anthem said that its offerings were losing money, but also that it would expand its participation if a pending merger with Cigna was approved.[437] Aetna and Humana’s exit for 2017 left 8 rural Arizona counties with only Blue Cross/Blue Shield.[438]
Blue Cross/Blue Shield Minnesota announced that it would exit individual and family markets in Minnesota in 2017, due to financial losses of $500 million over three years.[439]
Another analysis found that 17 percent of eligibles may have a single insurer option in 2017. North Carolina, Oklahoma, Alaska, Alabama, South Carolina and Wyoming were expected to have a single insurer,[440] while only 2 percent of 2016 eligibles had only one choice.[441]
Aetna, Humana, UnitedHealth Group also exited various individual markets. Many local Blue Cross plans sharply narrowed their networks. In 2016 two thirds of individual plans were narrow-network HMO plans.[425]
One of the causes of insurer losses is the lower income, older and sicker enrollee population. One 2016 analysis reported that while 81% of the population with incomes from 100-150% of the federal poverty level signed up, only 45% of those from 150-200% did so. The percentage continued to decline as income rose: 2% of those above 400% enrolled.[442]
Costs
The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance, based on income levels. Higher income consumers receive lower subsidies. While pre-subsidy prices rose considerably from 2016 to 2017, so did the subsidies, to reduce the after-subsidy cost to the consumer. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas.[221] However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reported that for the second-lowest cost “Silver plan” (a plan often selected and used as the benchmark for determining financial assistance), a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the subsidy/tax credit, despite large increases in the pre-subsidy price. This was consistent nationally. In other words, the subsidies increased along with the pre-subsidy price, fully offsetting the price increases.[222]
Cooperatives
The number of ACA nonprofit insurance cooperatives for 2017 fell from 23 originally to 7 for 2017. The remaining 7 posted annual losses in 2015. A General Accountability Report found that co-ops’ 2015 premiums were generally below average. At the end of 2014, money co-ops and other ACA insurers had counted on risk corridor payments that didn’t materialize. Maryland’s Evergreen Health claims that ACA’s risk-adjustment system does not adequately measure risk.[citation needed]
Medicaid
Newly elected Louisiana Governor John Bel Edwards issued an executive order to accept the expansion, becoming the 32nd state to do so. The program was expected to enroll an additional 300,000 Louisianans.[443]
2017
More than 9.2 million people signed up for care on the national exchange (healthcare.gov) for 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump, who pulled advertising encouraging people to signup for coverage, issued an executive order that attempts to eliminate the mandate, and has created significant uncertainty about the future of the ACA. Enrollments had been running ahead of 2016 prior to President Obama leaving office, with 9.8 million expected to sign-up, so President Trump’s actions potentially cost about 600,000 national enrollments (i.e., 9.8 million expected – 9.2 million actual = 0.6 million impact).[444]Of the 9.2 million, 3.0 million were new customers and 6.2 million were returning. The 9.2 million excludes the 11 states that run their own exchanges, which have signed up around 3 million additional people.[444] These figures also exclude the additional coverage due to the Medicaid expansion, which covers another approximately 10 million persons, as described in the impact section above.
In February, Humana announced that it would withdraw from the individual insurance market in 2018, citing “further signs of an unbalanced risk pool.”[445] That month the IRS announced that it would not require that tax returns indicate that a person has health insurance, reducing the effectiveness of the individual mandate, in response to an executive order from President Donald Trump.[446]
Aetna CEO Mark Bertolini stated that ACA was in a “death spiral” of escalating premiums and shrinking, skewed enrollment.[447] However, a U.S. judge found that the Aetna CEO misrepresented why his company was leaving the exchanges; an important part of the reason was the Justice Department’s opposition to the intended merger between Aetna and Humana. Aetna actually pulled out of states where it was making money on the exchanges, while remaining in some states where it was not.[448] Further, the CBO reported in March 2017 that the healthcare exchanges were expected to be stable; i.e., they were not in a “death spiral.”[449]
Molina Healthcare, a major Medicaid provider, said that it was considering exiting some markets in 2018, citing “too many unknowns with the marketplace program.” Molina lost $110 million in 2016 due to having to contribute $325 million more than expected to the ACA “risk transfer” fund that compensated insurers with unprofitable risk pools. These pools were establish to help prevent insurers from artificially selecting lower-risk pools.[450]
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The Pronk Pops Show 1075, May 10, 2018, Story 1: Obama “Deep Throat” Mole and Agent Provocateur In Trump Campaign — Obama FBI/CIA Confidential Informants (CI) or Confidential Human Sources Spied on Trump Campaign — Who Is FBI/CIA Deep Throat Mole and Agent Provocateur — Stefan Halper? — Trump Knows — Trump Waiting For Ideal Moment To Declassify Documents Congress Subpoenaed — 2018 October Surprise! –Videos — Story 2: President Donald Trump and Vice President Pence Welcome Home Three Americans Held Hostage in North Korea By Kim Jong-un Regime — Videos
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Pronk Pops Show 1075, May 10, 2018
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Pronk Pops Show 1026, February 1, 2018
Story 1: Obama “Deep Throat” Mole and Agent Provocateur In Trump Campaign — Obama FBI/CIA Confidential Informants (CI) or Confidential Human Sources Spied on Trump Campaign — Who Is FBI/CIA Deep Throat Mole and Agent Provocateur — Stefan Halper? — Trump Knows — Trump Waiting For Ideal Moment To Declassify Documents Congress Subpoenaed — 2018 October Surprise! –Videos —
]
Did an FBI spy infiltrate the Trump 2016 campaign?
Dan Bongino – There Were Two Moles in the Trump Tent, 2217
Rep. Peter King on possibility of Trump campaign mole
After CIA-MI6 Operative Stefan Halper Confirmed As Mole FBI Director Comey Used To Destroy Trump
World In Shock After CIA-MI6 Operative Stefan Halper Confirmed As Mole
FBI may have placed a mole inside the Trump campaign: report
Strassel: Did FBI outright spy on the 2016 Trump campaign?
Did an FBI spy infiltrate the Trump 2016 campaign?
Strassel: FBI used human intel to spy on Trump campaign
Mark Felk, Aka “Deep Throat” Dead at 95
New: CIA Agent Whistleblower Risks All To Expose The Shadow Government
John Brennan faces scrutiny over anti-Trump dossier
Rosenstein under fire from Trump, Congress
Judicial Watch: FBI advised Comey to consult with Mueller
Mark Levin: Mueller’s purpose is to remove the president
Vice President Pence calls on Mueller to “wrap it up”
Ryan backs Nunes in feud with DOJ
Hannity: Mueller probe suffers two major blows
Time for Mueller to show his cards: Fmr. Prosecutor Andrew McCarthy
AN OBAMA FBI INFORMANT PLANTED INSIDE THE TRUMP CAMPAIGN
BREAKING FBI Planted Mole In Trump Administration… Spread This Like WILDFIRE
Fact-checking Obama’s denial of Trump wiretap claims
What happens if Obama was involved in illegal surveillance?
Rep. Nunes threatens AG sessions with contempt of Congress
Scalise turns up the heat on Attorney General Jeff Sessions
Deep state is weaponizing staff security clearances against Trump: Sean Bigley
Trump threatens to use presidential powers on DOJ
EVERY TREY GOWDY QUESTION: GRILLS John Brennan on Trump Russia Collusion Leaks Unmasking
Trump Claims Obama wiretapped Trump Tower | ABC News
Washington reacts to Trump’s claims of secret surveillance
What Are FBI Informants? Domestic Terrorism, Entrapment, Program, Payments (2011)
Ex Weatherman Larry Grathwohl – Obama’s mentor Bill Ayers wanted to kill millions like Mao
Larry Grathwohl Final Thoughts on Bill Ayers
Larry Grathwohl (Part 1 of 3) Soros Files
Larry Grathwohl (Part 2 of 3) The Soros Files
Larry Grathwohl (Part 3 of 3) The Soros Files
Freeway Ricky: Top Informants Make $5 Million a Year, Downfall of BMF
Joaquín “Jack” García Undercover FBI Agent Lecture at The Mob Museum
Jack Garcia on Being a Undercover FBI Agent in the Mob
The Secret Life of CIA and FBI Informants
Ex F.B.I Informant talks infiltration of BLACK CULTURE
LIKE IT IS: BLACK SPY TELLS ALL
One of the FBI’s Biggest Secrets: The Informant – A Bizarre Financial Scandal (2000)
FBI Informant Exposes Sting Operation Targeting Innocent Americans in New “(T)ERROR” Documentary
(T)ERROR Official Trailer 1 (2015) – Counterterrorism Documentary HD
(T)ERROR Documentary with Directors Lyric R. Cabral and David Felix Sutcliffe
(T)ERROR Documentary.Film 2015
Former FBI Asst. Director Bill Gavin on FBI spying on Trump campaign advisor
Fmr. FBI asst. director on wiretap claims: I warned Trump
Byron York reacts to Clapper denying wiretap of Trump
What we know about Stefan Halper and Joseph Mifsud | Jack Posobiec Periscope
Professor Joseph Mifsud Who Told Trump Campaign About Hillary Clinton “Dirt” From Russia Has Vanished
G7 International forum – Joseph Mifsud
Joseph Mifsud about World Energy Market Trends
All Russiagate Roads Lead To London As Evidence Emerges Of Joseph Mifsud’s Links To UK Intelligence
The Bill Walton Show: Episode 27 – “It’s Time to Get Serious About China” with Stefan Halper and…
Stefan Halper, “Legitimating Authoritarianism in Our Time”
Austin Powers The Spy Who Shagged Me: Why don’t we shag?
Austin Powers International Man Of Mystery: Miss Kensington
Austin Powers International Man Of Mystery: Alotta Fagina
May 12, 2018
World In Shock After CIA-MI6 Operative Stefan Halper Confirmed As Mole FBI Director Comey Used To Destroy Trump
By: Sorcha Faal, and as reported to her Western Subscribers
A somberly written new Ministry of Foreign Affairs (MoFA) report circulating in the Kremlin today states the entire world is in shock today after confirmation was received that an active CIA-MI6 operative named Stefan Halper was inserted as deep-cover spy (mole) into the US presidential campaign of Donald Trump by former FBI Director James Comey—and whose single role was to destroy Trump before he could achieve an election victory over his rival Hillary Clinton—but in whose failing to accomplish this feat, has exposed the United States as being a “failed state”whose grim future includes it possibly collapsing into civil war. [Note: Some words and/or phrases appearing in quotes in this report are English language approximations of Russian words/phrases having no exact counterpart.]
CIA-MI6 deep cover spy Stefan Halper’s task was to link and dirty up (make to look illicit) the connections between the Trump campaign and operatives associated with Russia
According to this report, though the United States has a long history of bitter and contentious presidential elections, the world community could always rely on the American’s conducting free and fair elections without interference from their powerful, and very secret, intelligence agencies—and that thus marked the US as being a reliable partner in the conducting of vital global affairs.
With the rise to US presidential power of New York City multi-billionaire real estate developer Donald Trump, however, this report notes, America’s powerful state intelligence apparatus, for the first time in its history, obliterated the US Constitution and all US laws in order to destroy presidential candidate Trump—and whose “device” to do so was described by the FBI’s Deputy Assistant Director of the Counterintelligence Division Peter Strzok as “The Insurance Policy”—but known today as the “Trump-Russia Dossier”.
Once secret texts of FBI Deputy Counter Terror Chief Peter Strzok reveal existence of “The Insurance Policy” to destroy Donald Trump
The creation of “The Insurance Policy” to destroy Donald Trump, this report explains, was as comically stupid as it was insidious—and involved British MI6 operative Christopher Steele being illegally paid millions-of-dollars by Hillary Clinton and her Democratic National Committeeto create what is known as the “Trump-Russia Dossier”—with Steele being aided in this effort by one of the Russian turncoat spies he had once recruited named Sergei Skripal—but with Skripal, and his daughter Yulia, being “taken out” after MI6 discovered that he had written to President Putin asking to be allowed to come back home to Russia.
Upon the completion of “Trump-Russia Dossier Insurance Policy” by MI6 operative Christopher Steele, this report continues, it was given to CIA Director John Brennan—who then recruited the notorious CIA-MI6 operative Stefan Halper to lure Trump campaign volunteer George Papadopoulos to London—with Halper paying $3,000 to Papadopoulos for a research paper, and that, also, covered the cost of his room, board, and flight to London.
Next to be ensnared by CIA-MI6 operative Stefan Halper, this report notes, was another Trump campaign volunteer named Carter Page—whom, like Papadopoulos before him, was lured to London by Halper.
Once he had the “Trump-Russia Dossier Insurance Policy”, and whatever lies were concocted by CIA-MI6 operative Stefan Halper, this report explains, CIA Director Brennan couldn’t use them as the CIA is forbidden to interfere in US domestic affairs—but with the workaround being having US Senator John McCain take “The Insurance Policy” from the CIA and give it to FBI Director James Comey—that the FBI had to admit they couldn’t verify any of its spurious claims—but didn’t stop them from shockingly using this information to become the first US intelligence agency to obtain a warrant to spy on the presidential campaign in all of history.
With the “Trump-Russia Dossier Insurance Policy” having failed to keep Trump from winning the US presidency, this report continues, any rationally thinking state intelligence agency would have buried everything about this sordid plot so far down it would never see the light of day, particularly because of how rapidly it could be exposed—but that, of course, didn’t happen because of the insane hatred everyone in power in the US had because of their now having to deal with President Donald Trump.
So, and in one of the most ill conceived and transparent coup plots ever devised, this report details, Director of National Intelligence James Clapper (who oversaw both the FBI and CIA) ordered FBI Director Comey to “brief” the newly elected President Trump about the existence of the “Trump-Russia Dossier Insurance Policy”—with Clapper, immediately afterwards, “leaking” this information to the “fake news” cable television media giant CNN, thus giving them the “hook” to call it “real news”—and for which Clapper was handsomely rewarded when CNN hired him for millions-of-dollars.
However, what DNI Clapper, FBI Director Comey and CIA Director Brennan failed to realize when they unleashed the “Trump-Russia Dossier Insurance Policy” against President Trump in retribution for his daring to defeat Hillary Clinton, this report says, was that the most vulnerable flaw in any intelligence operation are the operatives involved in it—most particularly in this case being CIA-MI6 operative Stefan Halper.
In anyone ever attempting to create in writing a description of what a “Deep State” operative would be like, this report explains, they’d be best not to even try and, instead, just describe the life of Stefan Halper—who, upon his graduation from an Ivy League university, traveled to London to get a Ph.D. at Cambridge, then returned to the United States where he was quickly hired by the President Nixon administration—married the daughter of one of the CIA’s most feared high-ranking directors—over the past nearly 50 years has worked in every single branch and department of the US government—ran a CIA covert operation to discredit former President Jimmy Carter—became an operative for the British intelligence agency MI6—and in his spare time, created a private bank used by the President Ronald Reagan administration to funnel money to both Iran and Central American terrorists (called Contras) trying to illegally overthrow the government of Nicaragua.
On 27 January 2017, seven days after President Trump took his oath of office, this report continues, FBI Director Comey had his agents interview George Papadopoulos—which immediately exposed CIA-I6 operative Stefan Halper as being a spy (mole) secretly placed into Trump’scampaign, that even a novice intelligence agent could follow the trail of—and though the “Deep State” is working feverishly to keep this fact hidden from the American public, the truest reporting coming from the US states that “the Obama State department, CIA, and FBI conspired to set “Russian espionage traps” for minor players in the Trump campaign, and the FBI had a mole within the Trump campaign, that giant sucking sound you might hear is nothing short of the US Intelligence community starting to implode”.
With the so-called Special Counsel Robert Mueller investigation of the “Trump-Russia Dossier Insurance Policy” being nothing more than a cover-up of Obama’s Department of Justice and FBI efforts to destroy the Trump Presidency, this report concludes, the real investigation currently ongoing is the one headed by Department of Justice Inspector General Michael Horowitz—whose exposure of the entire plot to overthrow Trump is about to explode upon the American political landscape—with former FBI supervisory special agent James Gagliano even warning his “fake news” colleagues at CNN what’s about to strike by his stating:
Sources with knowledge of the impending DOJ Inspector General Report confirm that it will be a fairly damning indictment of FBI’s seventh floor during the Comey era.
“It’s worse than expected,” seems to be the consistent theme.
“I’ve always won, and I’m going to continue to win. And that’s the way it is.”
45th President of the United States, Donald J. Trump
http://www.whatdoesitmean.com/index2560.htm
About That FBI ‘Source’
Did the bureau engage in outright spying against the 2016 Trump campaign?
By
The Department of Justice lost its latest battle with Congress Thursday when it agreed to brief House Intelligence Committee members about a top-secret intelligence source that was part of the FBI’s investigation of the Trump campaign. Even without official confirmation of that source’s name, the news so far holds some stunning implications.
Among them is that the Justice Department and Federal Bureau of Investigation outright hid critical information from a congressional investigation. In a Thursday press conference, Speaker Paul Ryan bluntly noted that Intelligence Chairman Devin Nunes’s request for details on this secret source was “wholly appropriate,” “completely within the scope” of the committee’s long-running FBI investigation, and “something that probably should have been answered a while ago.” Translation: The department knew full well it should have turned this material over to congressional investigators last year, but instead deliberately concealed it.
House investigators nonetheless sniffed out a name, and Mr. Nunes in recent weeks issued a letter and a subpoena demanding more details. Deputy Attorney General Rod Rosenstein’s response was to double down—accusing the House of “extortion” and delivering a speech in which he claimed that “declining to open the FBI’s files to review” is a constitutional “duty.” Justice asked the White House to back its stonewall. And it even began spinning that daddy of all superspook arguments—that revealing any detail about this particular asset could result in “loss of human lives.”
This is desperation, and it strongly suggests that whatever is in these files is going to prove very uncomfortable to the FBI.
The bureau already has some explaining to do. Thanks to the Washington Post’s unnamed law-enforcement leakers, we know Mr. Nunes’s request deals with a “top secret intelligence source” of the FBI and CIA, who is a U.S. citizen and who was involved in the Russia collusion probe. When government agencies refer to sources, they mean people who appear to be average citizens but use their profession or contacts to spy for the agency. Ergo, we might take this to mean that the FBI secretly had a person on the payroll who used his or her non-FBI credentials to interact in some capacity with the Trump campaign.
This would amount to spying, and it is hugely disconcerting. It would also be a major escalation from the electronic surveillance we already knew about, which was bad enough. Obama political appointees rampantly “unmasked” Trump campaign officials to monitor their conversations, while the FBI played dirty with its surveillance warrant against Carter Page, failing to tell the Foreign Intelligence Surveillance Court that its supporting information came from the Hillary Clinton campaign. Now we find it may have also been rolling out human intelligence, John Le Carré style, to infiltrate the Trump campaign.
Which would lead to another big question for the FBI: When? The bureau has been doggedly sticking with its story that a tip in July 2016 about the drunken ramblings of George Papadopoulos launched its counterintelligence probe. Still, the players in this affair—the FBI, former Director Jim Comey, the Steele dossier authors—have been suspiciously vague on the key moments leading up to that launch date. When precisely was the Steele dossier delivered to the FBI? When precisely did the Papadopoulos information come in?
And to the point, when precisely was this human source operating? Because if it was prior to that infamous Papadopoulos tip, then the FBI isn’t being straight. It would mean the bureau was spying on the Trump campaign prior to that moment. And that in turn would mean that the FBI had been spurred to act on the basis of something other than a junior campaign aide’s loose lips.
We also know that among the Justice Department’s stated reasons for not complying with the Nunes subpoena was its worry that to do so might damage international relationships. This suggests the “source” may be overseas, have ties to foreign intelligence, or both. That’s notable, given the highly suspicious role foreigners have played in this escapade. It was an Australian diplomat who reported the Papadopoulos conversation. Dossier author Christopher Steele is British, used to work for MI6, and retains ties to that spy agency as well as to a network of former spooks. It was a former British diplomat who tipped off Sen. John McCain to the dossier. How this “top secret” source fits into this puzzle could matter deeply.
Correction
The FBI briefed House Intelligence Committee members about a top-secret intelligence source but did not allow them to see documents. An earlier version of this article misstated this.
https://www.wsj.com/articles/about-that-fbi-source-1525992611
Secret intelligence source who aided Mueller probe is at center of latest clash between Nunes and Justice Dept.
The debate over the risk to the source is now at the center of a pitched battle between House Republicans and the Justice Department.
After the White House sided with the department’s decision to refuse the request, Nunes (R-Calif.) publicly vented his frustration, saying Sunday that he may try to hold Sessions in contempt for refusing to comply. He said that his classified-document request and subsequent subpoena to the Justice Department did not refer to an individual.
“They are citing spurious national security concerns to evade congressional oversight while leaking information to The Washington Post ostensibly about classified meetings,” he said in a statement to The Post. “Congress has a right and a duty to get this information and we will succeed in getting this information, regardless of whatever fantastic stories the DOJ and FBI spin to the Post.”
Several administration officials said they fear Trump may reverse course and support Nunes’s argument.
White House officials did not respond to requests for comment.
For the intelligence agencies, Nunes’s request threatened to cross a red line of compromising sources and methods of U.S. intelligence-gathering, according to people familiar with their views. Intelligence officials fear that providing even a redacted version of the information Nunes seeks could expose that person and damage relationships with other countries that serve as U.S. intelligence partners.
The role of the intelligence source in the Mueller investigation may now be seized upon by conservative Republicans who have publicly accused the Justice Department and intelligence agencies of overreach and misuse of their surveillance powers.
Some have alleged that officials within the government have worked against Trump, and they have criticized Deputy Attorney General Rod J. Rosenstein, who oversees the special counsel probe, for refusing to let members of Congress see a “scope memo” outlining the people and issues under investigation by Mueller.
Last month, House allies of Trump drafted articles of impeachment against Rosenstein as a “last resort” if he does not provide Congress with more information.
It’s not clear what documents Nunes requested in his classified April 24 letter to the Justice Department. He told reporters this week that he is investigating the FBI’s abuse of the Foreign Intelligence Surveillance Act “and other matters.”
Because Sessions is recused from the Russia investigation and investigations involving the 2016 campaign, he is not involved in the discussions surrounding Nunes’s request, according to a person familiar with the matter.
During a meeting at the White House last Wednesday, senior FBI and intelligence officials told Chief of Staff John F. Kelly that turning over the information could contradict years of policy about protecting intelligence sources, according to three people familiar with the matter. The people who described the meeting include those who support the release of the information and those opposed to it.
Kelly then consulted with Trump, who agreed it was important to protect intelligence sources, according to a person with knowledge of the conversation.
Assistant Attorney General Stephen E. Boyd laid out those concerns to Nunes in a letter the following day, noting that the department made the decision after “consultations” with the White House and intelligence agencies.
“Disclosure of responsive information to such requests can risk severe consequences including potential loss of human lives, damage to relationships with valued international partners, compromise of ongoing criminal investigations, and interference with intelligence activities,” Boyd wrote.
Nunes told reporters Monday that the Justice Department’s stance was “awfully suspicious,” suggesting that the White House did not share the department’s concerns.
“The word that comes to me is obfuscation,” he said.
On Tuesday, House Speaker Paul D. Ryan (R.-Wis.) said he had not discussed the matter with Nunes but added that he expected congressional subpoenas to be enforced.
“We expect the administration to comply with our document requests,” Ryan said.
The Justice Department has been sparring with lawmakers and congressional committees for months over document requests related to the FBI investigations. In most instances, officials have turned over materials.
At one point, Nunes had threatened to impeach top Justice Department officials when they did not immediately hand over an unredacted document detailing the origin of the investigation into whether the Trump campaign coordinated with Russia to influence the 2016 election. The department later gave Nunes access to a version with modest redactions, and Nunes thanked Rosenstein for his cooperation.
[Justice Dept. gives Nunes access to document on Russia probe’s origins, cooling his threat to impeach its leaders]
Rosenstein has sought to make clear in recent weeks that while he is willing to compromise, he will go only so far. Last week, in response to the revelation that members of the conservative House Freedom Caucus drafted articles of impeachment, Rosenstein declared that the Justice Department was “not going to be extorted” and would not hand over documents that might harm national security or ongoing investigations.
“If we were to just open our doors to allow Congress to come and rummage through the files, that would be a serious infringement on the separation of powers, and it might resolve a dispute today, but it would have negative repercussions in the long run, and we have a responsibility to defend the institution,” Rosenstein said.
Josh Dawsey, Karoun Demirjian and Matt Zapotosky contributed to this report.
https://www.washingtonpost.com/politics/risk-to-intelligence-source-who-aided-russia-investigation-at-center-of-latest-showdown-between-nunes-and-justice-dept/2018/05/08/d6fb66f8-5223-11e8-abd8-265bd07a9859_story.html?noredirect=on&utm_term=.7d4943870599
WSJ: The FBI Hid A Mole In The Trump Campaign
On Wednesday we reported on an intense battle playing out between House Intel Committee Chairman Devin Nunes (R-CA), the Department of Justice, and the Mueller investigation concerning a cache of intelligence that Deputy Attorney General Rod Rosenstein refuses to hand over – a request he equated to “extortion.”
On Tuesday, the Washington Post reported that Nunes was denied access to the information on the grounds that it “could risk lives by potentially exposing the source, a U.S. citizen who has provided intelligence to the CIA and FBI.”
After the White House caved to Rosenstein and Nunes was barred from seeing the documents, it also emerged that this same intelligence had already been shared with Special Counsel Robert Mueller as part of his investigation into alleged Russian involvement in the 2016 US election.
On Wednesday afternoon, however, news emerged that Nunes and House Oversight and Government Reform Committee Chairman Trey Gowdy (R-SC) would receive a classified Thursday briefing at the DOJ on the documents. This is, to put it lightly, incredibly significant.
Why? Because it appears that the FBI may have had a mole embedded in the Trump campaign.
In a bombshell op-ed in the Wall Street Journal, Kimberly Strassel shares a few key insights about recent developments. Perhaps we should start with the ending and let you take it from there. Needless to say Strassel’s claims, if true, would have wide ranging implications for the CIA, FBI, DOJ and former Obama administration officials.
Strassel concludes:
Authored by Kimberley Strassel, op-ed via The Wall Street Journal,
About That FBI ‘Source’
Did the bureau engage in outright spying against the 2016 Trump campaign?
The Department of Justice lost its latest battle with Congress Thursday when it allowed House Intelligence Committee members to view classified documents about a top-secret intelligence source that was part of the FBI’s investigation of the Trump campaign. Even without official confirmation of that source’s name, the news so far holds some stunning implications.
Among them is that the Justice Department and Federal Bureau of Investigation outright hid critical information from a congressional investigation. In a Thursday press conference, Speaker Paul Ryan bluntly noted that Intelligence Chairman Devin Nunes’s request for details on this secret source was “wholly appropriate,” “completely within the scope” of the committee’s long-running FBI investigation, and “something that probably should have been answered a while ago.” Translation: The department knew full well it should have turned this material over to congressional investigators last year, but instead deliberately concealed it.
House investigators nonetheless sniffed out a name, and Mr. Nunes in recent weeks issued a letter and a subpoena demanding more details. Deputy Attorney General Rod Rosenstein’s response was to double down—accusing the House of “extortion” and delivering a speech in which he claimed that “declining to open the FBI’s files to review” is a constitutional “duty.” Justice asked the White House to back its stonewall. And it even began spinning that daddy of all superspook arguments—that revealing any detail about this particular asset could result in “loss of human lives.”
This is desperation, and it strongly suggests that whatever is in these files is going to prove very uncomfortable to the FBI.
The bureau already has some explaining to do. Thanks to the Washington Post’s unnamed law-enforcement leakers, we know Mr. Nunes’s request deals with a “top secret intelligence source” of the FBI and CIA, who is a U.S. citizen and who was involved in the Russia collusion probe. When government agencies refer to sources, they mean people who appear to be average citizens but use their profession or contacts to spy for the agency. Ergo, we might take this to mean that the FBI secretly had a person on the payroll who used his or her non-FBI credentials to interact in some capacity with the Trump campaign.
This would amount to spying, and it is hugely disconcerting. It would also be a major escalation from the electronic surveillance we already knew about, which was bad enough. Obama political appointees rampantly “unmasked” Trump campaign officials to monitor their conversations, while the FBI played dirty with its surveillance warrant against Carter Page, failing to tell the Foreign Intelligence Surveillance Court that its supporting information came from the Hillary Clinton campaign. Now we find it may have also been rolling out human intelligence, John Le Carré style, to infiltrate the Trump campaign.
Which would lead to another big question for the FBI: When? The bureau has been doggedly sticking with its story that a tip in July 2016 about the drunken ramblings of George Papadopoulos launched its counterintelligence probe. Still, the players in this affair—the FBI, former Director Jim Comey, the Steele dossier authors—have been suspiciously vague on the key moments leading up to that launch date. When precisely was the Steele dossier delivered to the FBI? When precisely did the Papadopoulos information come in?
And to the point, when precisely was this human source operating? Because if it was prior to that infamous Papadopoulos tip, then the FBI isn’t being straight. It would mean the bureau was spying on the Trump campaign prior to that moment. And that in turn would mean that the FBI had been spurred to act on the basis of something other than a junior campaign aide’s loose lips.
We also know that among the Justice Department’s stated reasons for not complying with the Nunes subpoena was its worry that to do so might damage international relationships. This suggests the “source” may be overseas, have ties to foreign intelligence, or both. That’s notable, given the highly suspicious role foreigners have played in this escapade. It was an Australian diplomat who reported the Papadopoulos conversation. Dossier author Christopher Steele is British, used to work for MI6, and retains ties to that spy agency as well as to a network of former spooks. It was a former British diplomat who tipped off Sen. John McCain to the dossier. How this “top secret” source fits into this puzzle could matter deeply.
I believe I know the name of the informant, but my intelligence sources did not provide it to me and refuse to confirm it. It would therefore be irresponsible to publish it. But what is clear is that we’ve barely scratched the surface of the FBI’s 2016 behavior, and the country will never get the straight story until President Trump moves to declassify everything possible. It’s time to rip off the Band-Aid.
https://www.zerohedge.com/news/2018-05-10/wsj-fbi-hid-mole-trump-campaign
AN FBI INFORMANT IN THE TRUMP CAMPAIGN?
Rush Limbaugh summarizes Kim Strassel’s Wall Street Journal column of this past Friday, today’s Wall Street Journal editorial (obviously written by Kim), and a related Washington Post story in which the deep state strikes back against House Intelligence Committee Chairman Devin Nunes. It’s a complicated story to unravel. In the transcript posted at his site, Rush links to each of the three sources and summarizes the salient details.
Close reading is required, and Rush zooms in to provide it. There seems to be a serious question whether the FBI had an informant in the Trump campaign.
At last word, Chairman Nunes and Rep. Trey Gowdy had met with Rod Rosenstein, FBI and intelligence authorities. They agreed to keep talking about obtaining the documents in issue (statement embedded in tweet below).
View image on Twitter
What is going on here? Kim Strassel comments today in her tweet below. Support Devin Nunes!
T H E ATTORNEY GENERAL’S GUIDELINES REGARDING
T H E USE OF FBI CONFIDENTIAL HUMAN SOURCES
EXCLUSIVE: A London Meeting Before The Election Aroused George Papadopoulos’s Suspicions
Two months before the 2016 election, George Papadopoulos received a strange request for a meeting in London, one of several the young Trump adviser would be offered — and he would accept — during the presidential campaign.
The meeting request, which has not been reported until now, came from Stefan Halper, a foreign policy expert and Cambridge professor with connections to the CIA and its British counterpart, MI6.
Halper’s September 2016 outreach to Papadopoulos wasn’t his only contact with Trump campaign members. The 73-year-old professor, a veteran of three Republican administrations, met with two other campaign advisers, The Daily Caller News Foundation learned.
Papadopoulos now questions Halper’s motivation for contacting him, according to a source familiar with Papadopoulos’s thinking. That’s not just because of the randomness of the initial inquiry but because of questions Halper is said to have asked during their face-to-face meetings in London.
According to a source with knowledge of the meeting, Halper asked Papadopoulos: “George, you know about hacking the emails from Russia, right?”
Papadopoulos told Halper he didn’t know anything about emails or Russian hacking, said the source, who spoke on the condition of anonymity due to the sensitivity of the investigations into Russian meddling in the 2016 campaign. The professor did not follow up on the line of inquiry.
Halper first contacted Papadopoulos by email. In a Sept. 2, 2016, message sent to Papadopoulos’s personal email account, he offered the Trump aide $3,000 to write a policy paper on issues related to Turkey, Cyprus, Israel and the Leviathan natural gas field. Halper also offered to pay for Papadopoulos’s flight and a three-night stay in London.
Papadopoulos accepted the proposal, flew to England, and met with Halper and one of his assistants. He delivered the paper electronically Oct. 2 and received payment days later, according to documents TheDCNF reviewed.
Halper’s encounters with Papadopoulos were not the only encounters that the professor had with the Trump campaign.
[Stefan Halper speaks at Wellesley College, Oct. 23, 2013. (YouTube screen capture)]
Halper met campaign foreign policy adviser Carter Page at a July 2016 symposium held at Cambridge regarding the upcoming election, Page told TheDCNF. The pair remained in contact for several months.Halper also requested and attended a one-on-one meeting with another senior campaign official, TheDCNF learned. That meeting was held a day or two before Halper reached out to Papadopoulos. Halper offered to help the campaign but did not bring up Papadopoulos, even though he would reach out to the campaign aide a day or two later.
Halper’s intentions are unclear, while a source familiar with the investigations into Russian meddling told TheDCNF Halper’s name popped up on investigators’ radar. There is no indication of any wrongdoing on his part, and it is not clear if he has been in touch with investigators.
Halper’s activities are all the more eye-catching because Papadopoulos and Page are central figures in the Russia investigation. Papadopoulos, 30, pleaded guilty in October 2017 to lying to the FBI about contacts he had during the campaign with Russian nationals and a London-based professor with links to the Russian government.
That professor, Joseph Mifsud, told Papadopoulos in April 2016 he learned the Russians had possession of “thousands” of Clinton-related emails. That conversation would later spark the FBI’s investigation into Russian interference in the presidential campaign. It is not known whether Papadopoulos told anyone on the Trump campaign about Mifsud’s remarks.
Page is also a prominent figure in the investigation due to allegations made against him in the infamous Steele dossier. Page’s trip to Moscow in early July 2016 is a central piece of the dossier. Christopher Steele, the author of the Democrat-funded report, alleges Page met secretly with two Kremlin insiders as part of the Trump campaign’s collusion effort.
Page attended the Cambridge event Halper set up, four days after that trip to Moscow.
***
London was a veritable stomping ground for Papadopoulos during the campaign.
In addition to meetings there with Halper and Mifsud, the Chicago native had an encounter that would serve as the catalyst for the FBI’s investigation into Russian meddling.
In May 2016, a month after his meeting with Mifsud, an Israeli embassy official, who Papadopoulos knew, introduced him to Australian High Commissioner to the United Kingdom Alexander Downer.
During a barroom conversation at Kensington Gardens, Papadopoulos told Downer about the emails Mifsud mentioned to him, The New York Times reported in December 2016.
After WikiLeaks published a trove of stolen DNC emails in July 2016, Australian government officials told the FBI about Downer’s interaction with Papadopoulos. The bureau opened its counterintelligence investigation July 31, 2016.
[Alexander Downer, Australia’s High Commissioner to the United Kingdom. (YouTube screen capture/BBC)]
What remains unclear is why Downer sought the meeting with Papadopoulos. Was it to become acquainted with a member of Trump’s foreign policy advisory team, or was it an opportunity to gather intelligence?The latter scenario — of a spy operation — is what Papadopoulos wonders was at play when Halper contacted him before the election. There are no clear connections between Halper and Downer, though the pair did speak on the same panel at a 2010 Cambridge seminar.
Papadopoulos and Halper met several times during the London trip, including at the Connaught Hotel and the Travellers Club — a classic 19th century club foreign diplomats and politicians frequent. Halper’s research assistant — a Turkish woman named Azra Turk — also met with Papadopoulos. The Connaught Hotel meeting was scheduled for Sept. 13, 2016, and the Travellers Club conclave was two days later.
While discussing the policy paper Papadopoulos was to write, Halper made an out-of-left-field reference to Russians and hacked emails, according to a source with direct knowledge of Papadopoulos’s version of events.
Turk contacted Papadopoulos to thank him for attending after the meeting. Papadopoulos delivered the paper through email Oct. 2.
Neither Halper nor Turk responded to numerous requests for comment. A phone call placed to a number listed for Halper was answered by a man who claimed Halper was not available. A message left with the man was not returned. Halper also did not reply to a detailed list of questions about his interactions with Trump campaign advisers.
Halper’s resume provides mixed clues about why he might have reached out to Papadopoulos.
On one hand, he worked on several geopolitical policy projects as a contractor for the Department of Defense’s Office of Net Assessment, the Pentagon’s in-house think tank. Federal records show he has been paid $928,800 since 2012 on four separate research projects.
At the time of the Papadopoulos meeting, Halper was working on a project related to China and Russia’s economic relations. There are no public records of Halper releasing reports on Turkey, Cyprus and Israel.
Fitting with Papadopoulos’s theory of Halper’s outreach is the professor’s longstanding connections to both British and American intelligence agency officials. He also worked at the Department of State, Department of Defense, Department of Justice, and in three presidential administrations.
Halper is a close associate of Sir Richard Dearlove — the former MI6 chief.
In December 2016, Halper, Dearlove and espionage historian Peter Morland made international news when they announced they were leaving an organization called the Cambridge Intelligence Seminar due to concerns Russian operatives had infiltrated the group.
Months earlier, in early fall 2016, Dearlove reportedly met with dossier author Steele. Steele sought out Dearlove’s advice on how to proceed with information he gathered on Trump’s ties to Russia, The Washington Post reported. Former MI6 Moscow station chief Steele had been told Trump campaign members were colluding with Kremlin operatives to release emails stolen from the DNC.
[Sir Richard Dearlove, former head of MI6. (YouTube screen capture/BBC)]
Steele’s dossier does not mention Papadopoulos, though the former spy was made aware of the Trump campaign aide while he was working on his anti-Trump document. FBI agents asked Steele during an October 2016 meeting in Rome if he was aware of Papadopoulos. Steele did not have information on Papadopoulos, the former spy said.But Papadopoulos does have at least one possible connection to the dossier. During the campaign, Sergei Millian approached him. Millian is a Belarus-born businessman who was allegedly an unwitting source for some of the most salacious claims in the dossier.
Halper also had connections to the CIA — most notably through his late father-in-law, Ray Cline.
Cline once served as director of the CIA’s bureau of intelligence and research. He was also the agency’s top analyst during the Cuban Missile Crisis. Halper got a job as foreign policy director on George H.W. Bush’s unsuccessful 1980 presidential primary bid on Cline’s recommendation.
Halper, who has a residence in Virginia, was also allegedly in charge of a team of former CIA analysts who kept tabs on the Jimmy Carter campaign.
In an ironic twist given the Russia probe’s focus on election meddling, Halper was also linked to a Reagan-era scandal dubbed “Briefing-gate.”
Halper was one of several Reagan White House officials linked to the scandal, which involved campaign briefing materials stolen from Carter’s campaign. Prior to the 1980 election, stolen Carter-campaign briefing papers containing classified information ended up in the hands of Reagan’s campaign officials.
The theft was not revealed until 1983. Halper was not directly implicated in stealing the documents, but he was identified as one of the campaign advisers who handled and disseminated them.
http://dailycaller.com/author/chuck-ross/
Stefan Halper (born 1944) is a foreign policy scholar. He served as a White House official in the Nixon, Ford, and Reagan administrations and is currently the Director of American Studies at the Department of Politics, University of Cambridge.[1] He is also a Life Fellow at Magdalene College, Cambridge.
He is the co-author of the bestselling book, America Alone: The Neo-Conservatives and the Global Order published by the Cambridge University Press (2004), and The Silence of the Rational Centre: Why American Foreign Policy is Failing (Basic Books, 2007). In April 2010, his book The Beijing Consensus: Legitimizing Authoritarianism in our Time, was published by Basic Books. Also a “best seller,” it has been published in Japan, Taiwan, China, South Korea and France.
Background and education
Halper graduated from Stanford University in 1967 and gained a doctorate in philosophy from the University of Oxford (1971) and the University of Cambridge (2004).[2][1] Halper is the son-in-law of Ray S. Cline.[3]
Career
US government (1971 – 1984)
Halper began his US government career in 1971 in the United States Domestic Policy Council, part of the Executive Office of the President of the United States, serving until 1973.[2] He then served in the Office of Management and Budget until 1974, when he moved to the Office of the White House Chief of Staff as Assistant to the Chief of Staff where he had responsibility for a range of domestic and international issues. During this time, Halper worked as an assistant for three Chiefs of Staff, Alexander Haig, Donald Rumsfeld, and Dick Cheney. He held this position until January 20, 1977.[2]
In 1977 Halper became Special Counsel to the Congressional Joint Economic Committee and Legislative Assistant to Senator William V. Roth, Jr. (R-Del.).[2] In 1979 he became National Policy Director for George H. W. Bush‘s Presidential campaign and then in 1980 he became Director of Policy Coordination for the Reagan- Bush Presidential campaign.[2] In connection with this position Halper’s name came up in the 1983/4 investigations into the Debategate affair.[3]
After Reagan entered the White House, Halper became Deputy Assistant Secretary of State for Political-Military Affairs.[2] Upon leaving the Department in 1984, he remained a Senior Advisor to the Department of Defense and a Senior Advisor to the Department of Justice until 2001.[2]
Academic and media career
From 1986 to 2000 Halper wrote a national security and foreign policy-focused weekly newspaper column, syndicated to 30 newspapers.[2]
Halper has worked as a senior foreign policy advisor to various think-tanks and research institutions, including the Center for Strategic and International Studies, The Center for the National Interest, where he is a Distinguished Fellow, and The Institute of World Politicswhere he is a Research Professor. He has served on the Advisory Board of Directors of the Paul H. Nitze School of Advanced International Studies and contributed to various magazines, journals, newspapers and media outlets. These include: The National Interest, The Washington Times, The Washington Post, The Los Angeles Times, The Wall Street Journal, The American Spectator, the BBC, CNN, SKY NEWS, ABC, CBS, NBC, C-Span, and a range of radio outlets.
Professor Halper is a member of the Cosmos Club in Washington, and the Travellers Club in London. He is a recipient of the State Department’s Superior Honor Award, the Justice Department’s Director’s Award and the Defense Department’s Superior Honor Award.
Business career
From 1984 to 1990 Halper was chairman and majority shareholder of the Palmer National Bank of Washington, D.C., the National Bank of Northern Virginia and the George Washington National Bank.[2]
References
External links
https://en.wikipedia.org/wiki/Stefan_Halper
Joseph Mifsud
Malta
University of Padua (MA)
Queen’s University Belfast (PhD)
Diplomacy
Link Campus University[1]
Joseph Mifsud (born 1960)[2] is a Maltese academic, with high level connections to the Russian state.[3]
He is a former employee of the Ministry of Foreign Affairs of Malta, a former principal in the London Centre of International Law Practice, a professorial teaching fellow at the University of Stirling[4] in Scotland, and director of the Diplomatic Academy of London,[5] where he held seminars on Brexit.[6]
He was awarded a PhD upon acceptance of his thesis entitled “Managing educational reform: a comparative approach from Malta (and Northern Ireland); a headteachers’ perspective” in 1995 from Queen’s University Belfast.[7]
Investigators say Mifsud enticed George Papadopoulos, an advisor to the 2016 Donald Trump presidential campaign, with a promise of Russian “dirt” on Hillary Clinton.[1][8]
He is a Member of the European Council on Foreign Relations (ECFR),[9] and a former President of the Euro-Mediterranean University of Slovenia (EMUNI).[10] He was a regular at meetings of the Valdai Discussion Club, an annual conference held in Sochi, Russia, attended by Vladimir Putin.[8]
On February 27, 2018, Buzzfeed News reported that Mifsud claimed to his former girlfriend that he was friends with Russian foreign minister Sergei Lavrov.[11] Mifsud has subsequently gone missing, having been seen last on October 31, 2017.[12]
On March 21, 2018, The BBC revealed that Mifsud introduced Papadopoulos in April 2016 via email to Ivan Timofeev, who works for a think tank close to the Russian Ministry of Foreign Affairs. In the same month, Mifsud was in Moscow on a panel run by the Kremlin-backed Valdai Club with Timofeev and a third man, Dr Stephan Roh, a German multi-millionaire described as a “wheeler-dealer”. Roh could not be reached for comment by the BBC and has since attempted to erase links between the two men on his company website.[13]
See also
References
https://en.wikipedia.org/wiki/Joseph_Mifsud
Story 2: President Donald Trump and Vice President Pence Welcome Home Three Americans Held Hostage in North Korea By Kim Jong-un Regime Regime — Videos
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‘We want to thank Kim Jong-un’: Trump praises North Korean leader for freeing three American prisoners ‘early’ as he and Melania give them heroes’ welcome as they land back at U.S. Air Force base
By Martin Robinson, Chief Reporter For Mailonline and David Martosko, Us Political Editor For Dailymail.com
PUBLISHED: 02:15 EDT, 10 May 2018 | UPDATED: 16:34 EDT, 10 May 2018
Donald Trump welcomed three Americans imprisoned in North Korea back to the U.S. in the wee hours of Thursday morning, and said words most observers thought no American president would ever utter: ‘We want to thank Kim Jong Un.’
The president and his wife Melania arrived at Joint Base Andrews outside Washington at 2:00 a.m. to greet Kim Dong Chul, Kim Hak Song and Tony Kim, and called them ‘incredible people.’
In extraordinary scenes, Trump and the first lady clapped and cheered as the men walked down the steps with their arms in the air and giving triumphant ‘V’ signs signifying both peace and victory.
Their first steps back on American soil came hours earlier, in Alaska, when the plane carrying them home stopped to refuel.
On the tarmac in suburban Maryland, Trump said: ‘These are great people. Frankly, we didn’t think this was going to happen, but it did. It was important to get these people out. This is a special night for these three really great people.’
Trump also thanked Kim Jong-un for freeing ‘the folks early.’ calling it ‘a wonderful thing’ and adding he believes the North Korean despot ‘really wants to do something’ and bring the hermit kingdom ‘into the real world.’
He said: ‘We’re starting off on a new footing. I really think we have a very good chance of doing something very meaningful, and if anybody would’ve said that five years ago, 10 years ago, even a year ago, you would’ve said, ‘That’s not possible.’
‘My proudest achievement will be when we denuclearize that entire [Korean] peninsula,’ he added.
The freed trio were joined by a translator who relayed their sentiment that being home felt ‘like a dream’ and that the men were ‘very, very happy’ to be freed. They later gave President Trump a round of applause.
Kim Dong-chul, speaking about his time in North Korea, said: ‘We were treated in many different ways. For me, I had to do a lot of labor. But when I got sick, I was also treated by them.’
Scroll down for video
Donald Trump and Melania welcomed three Americans imprisoned in North Korea back to America to cheers and applause
Trump shook hands with former detainee Kim Dong-chul (center) upon his return with Kim Hak-song and Tony Kim (both behind) in extraordinary scenes
Trump also thanked the North Korean dictator for freeing ‘the folks early,’ calling it ‘a wonderful thing’ and adding that he believes Kim finally wants to bring his country ‘into the real world’
President Trump, first lady Melania and Vice President Mike Pence walked with the freed Americans after they landed at Joint Base Andrews in Maryland
The three men were released Wednesday after up to three years of imprisonment and hard labor when Secretary of State Mike Pompeo left Pyongyang following a meeting with Kim to formalize final plans for a Trump-Kim summit in late May or early June.
He added that the talks between his administration and the North Korean government have ‘never been taken this far.’
While Trump said North Korea’s Kim Jong Un ‘was excellent to these three incredible people,’ Vice President Mike Pence hinted in an ABC interview they had endured harsh conditions.
Pence said Secretary of State Mike Pompeo told him that at a refueling stop in Anchorage, ‘one of the detainees asked to go outside the plane because he hadn’t seen daylight in a very long time.’
Who are the Americans freed by North Korea today?
Kim Dong Chul
A naturalized U.S. citizen born in South Korea, Kim Dong Chul was seized in North Korea on October 2, 2015 and accused of spying.
Though a resident of Virginia – he became an American citizen in 1987 – Kim had lived with his wife in Yanji, China since 2001.
He worked just across the North Korean border in the Rason-Sonbong special economic zone, where he ran a hotel services company. He was also a pastor.
Very little was known about his status until a CNN news crew interviewed him during their visit to Pyongyang in January 2016.
He told reporters during a news conference organized by the dictatorship two months later that he was a spy, explaining that he ‘apologized for trying to steal military secrets in collusion with South Koreans’ and called his own actions ‘unpardonable.’
The North accused him of receiving a USB drive and various papers containing nuclear secrets during a meeting with a defector from the regime.
After a one-day trial in April, he was sentenced to 10 years of hard labor for his supposed espionage.
But previous victims of the regime have explained that they were forced to make similar public declarations of their guilt after being tortured, despite being innocent.
Kim Hak-song
Kim Hak-song, also known as Jin Xue Song, had been working for the Pyongyang University of Science and Technology (PUST), undertaking agricultural development work with the school’s farm.
He was arrested at a Pyongyang railway station in May 2017 on suspicion of committing ‘hostile acts’ against the government, as he was boarding a train headed for his home in Dandong, China.
Kim, who is in his mid 50s, was born in Jilin, China, and educated at a university in California, CNN reported, citing a man who had studied with him.
He said Kim returned to China after about 10 years of living in the U.S., where he is a citizen.
PUST was founded by evangelical Christians overseas and opened in 2010, and is known to have a number of American faculty members.
Pupils are generally children from among the North’s elite.
It is not known whether Kim was sentenced for his supposed ‘hostile acts.’
Korean-American Kim Sang-duk – known as Tony Kim – was arrested in April 2017 at Pyongyang’s main airport as he tried to leave the country after teaching for several weeks as a guest lecturer, also at PUST.
Kim is a former professor at Yanbian University of Science and Technology in China, close to the Korean border.
Its website lists his speciality as accounting.
He graduated from the University of California Riverside in 1990 with a master’s degree in business administration.
South Korea’s Yonhap news agency has reported Kim as being in his late 50s and said he had been involved in relief activities for children in rural parts of North Korea.
It cited a source who described him as a ‘religiously devoted man.’
He was detained with his wife at Sunan International Airport in Pyongyang on April 22, 2017 while waiting for a flight.
Police later arrested Kim but did not explain why. His wife was allowed to leave the country.
PUST said the arrest was not related to his work at the university.
In a Facebook post, Kim’s son had said that his family has had no contact with him since his arrest.
Kim will soon become a grandfather.
But he did admit it was possible that ‘one day’ he may visit Pyongyang, should peace talks continue to go well.
The three former detainees were taken to Walter Reed National Military Medical Center for evaluation and medical treatment before being reunited with their families.
Singapore is the likely site for the historic meeting between the U.S. President and North Korea’s dictator. The summit could last up to two days.
When asked if the talks will lead to prolonged peace, the president said: ‘We’ll see how it all works out. Maybe it will, maybe it won’t, but it can be a great thing for North Korea, South Korea, Japan and the entire world. We hope it all works out.’
In usual Trumpian fashion, the president also joked with reporters, saying: ‘I think you probably broke the all-time-in-history television rating for 3 o’clock in the morning.’
The highly public display stood in stark contrast to the low-key private reception the State Department had envisioned, and in keeping with a tradition of trying to protect potentially traumatized victims from being thrust into the spotlight so soon after their ordeal.
Department officials took great pains on the prisoners’ release in North Korea, as well as on their flights to Japan and Alaska, to keep them sequestered not only from the two journalists traveling with Pompeo but also from staffers not immediately involved in their cases.
The trio, along with medical personnel, including a psychiatrist, were cloistered in the middle of Pompeo’s plane in a small section of 12 business class-size seats that was cordoned off by curtains on both ends.
State Department officials refused to discuss anything but the most basic details of their conditions, citing privacy concerns in keeping with the minimal amount of information they had released since the men were imprisoned.
The Americans had boarded Pompeo’s plane out of North Korea without assistance and then transferred in Japan to the Boeing C-40 outfitted with medical facilities for the trip back to the US.
Shortly after they touched down on American soil in Alaska – for a refueling stop Wednesday afternoon – the State Department released a statement from the freed men.
‘We would like to express our deep appreciation to the United States government, President Trump, Secretary Pompeo, and the people of the United States for bringing us home,’ they said. ‘We thank God, and all our families and friends who prayed for us and for our return. God Bless America, the greatest nation in the world.’
The release of the three men was only sealed about an hour before the secretary of state left the North Korean capital.
They walked on their own from a van and onto the plane, the culmination of Pompeo’s 12-hour visit to the North Korean capital, which included a 90-minute meeting with leader Kim Jong Un.
Returning to his hotel from that meeting, Mr Pompeo had given reporters a fingers-crossed sign when asked if there was good news about the detainees.
President Donald Trump arrives to greet the three Americans formerly held hostage in North Korea, at Joint Base Andrews, Maryland
A North Korean official came to the hotel shortly after to inform Pompeo that Kim had granted amnesties to the three and that they would be released at 7:00 p.m. local time, according to a senior U.S. official present for the exchange.
Carl Risch, the assistant secretary of state for consular affairs, and a doctor went to another hotel to pick up the men and bring them to the airport, the official said.
They finally left custody at 7.45 p.m., and by 8.42 p.m. they were flying home.
As soon as the plane cleared North Korean airspace, Mr Pompeo called Mr Trump to inform him of the releases – with the men all apparently in good health.
Even before Mr Pompeo’s plane had touched down for a stopover at Yokota Air Base in neighboring Japan, the president announced to the world on Twitter that the ‘3 wonderful gentlemen’ were free.
In a statement released by the State Department, the former detainees expressed their ‘deep appreciation’ to the U.S. government, Trump, Pompeo and the American people ‘for bringing us home.’
The three were the latest in a series of Americans who have been detained by North Korea in recent years for seemingly small offenses and typically freed when senior U.S. officials or statesmen personally visited to bail them out.
The last American to be released before this, college student Otto Warmbier, died in June 2017, days after he was repatriated to the U.S. with severe brain damage.
Warmbier was arrested by North Korean authorities in January 2016, accused of stealing a propaganda poster and sentenced to 15 years in prison with hard labor. His parents, Fred and Cindy Warmbier, have filed a wrongful death lawsuit, accusing the government of torturing and killing their son.
‘We are happy for the hostages and their families,’ the Warmbiers said in a statement Wednesday. ‘We miss Otto.’
After the release of the detainees, North Korea’s state-run media explicitly mentioned plans for the summit for the first time. Pyongyang has been exceptionally cautious about its public framing of Kim’s recent diplomatic moves, which are a major shift from the more aggressive focus on missile launches and nuclear development that heated tensions to a boil last year.
The trio’s release draws a line under an issue that had weighed on plans for a historic summit between Mr Kim and Mr Trump that will focus on North Korea’s nuclear weapons.
‘We’re granting amnesty to the three detained Americans,’ the North Korean emissary told Mr Pompeo at Pyongyang’s Koryo Hotel, according to the senior U.S. official.
‘We issued the order to grant immediate amnesty to the detainees.’
‘That’s great,’ the secretary of state replied.
The North Korean official then advised that the releases would follow a ‘very brief ceremony’ – which he described as more like a legal process.
The official closed with a gentle warning for the United States to prevent a repeat: ‘You should make care that they do not make the same mistakes again,’ the official said. ‘This was a hard decision.’
President Donald Trump tweeted late Wednesday that he was ‘Looking forward to greeting the Hostages (no longer) at 2:00 A.M.’
University founded by Christian Korean-American who was once detained in North on suspicion of being a spy
The university where two of the latest three American detainees released by North Korea taught is unique: an institution founded and funded by foreign Christians in an isolated country that decries religion.
The Pyongyang University of Science and Technology (PUST) was set up by James Kim, a wealthy evangelical Korean-American the North once detained on suspicion of being a U.S. spy.
Only North Korean citizens can enrol, and it is known to educate many children of the country’s elite.
Opened in 2010, it now has 560 students and 100 ‘international volunteers,’ according to its website, many of them coming to it through church organisations.
PUST says its mission is ‘to pursue excellence in education, with an international outlook, so that its students are diligent in studies, innovative in research and upright in character, bringing illumination to the Korean people and the world.’
But sources stress that it carries out no Christian proselytising, which is unwelcome by Pyongyang.
Although religious freedom is enshrined in the North Korean constitution, it does not exist in practice and religious activity is severely restricted to officially recognized groups linked to the government.
Agricultural expert Kim Hak-song and former accounting professor Tony Kim were both lecturers at the institution but were arrested by North Korean authorities as they were leaving the country.
The university previously said their detentions were ‘not connected in any way with the work of PUST,’ and it is understood the duo may have come to the attention of the Pyongyang authorities through previous Christian activities elsewhere.
The two, along with fellow detainee Kim Dong-chul, were granted ‘amnesty’ by Pyongyang following a meeting between Secretary of State Mike Pompeo and North Korean leader Kim Jong Un, and landed back in the United States on Thursday, to be welcomed by President Donald Trump.
‘Our hopes and prayers have been fulfilled by their release,’ PUST said in a statement. The university expressed ‘sincere hope’ that the detainees would be able to ‘now enjoy some peace and rest with their families and friends, and begin to rebuild normal life.’
The school itself has faced indirect repercussions from their detentions.
Tony Kim was arrested in April last year, Kim Hak-song the following month. Weeks later American student Otto Warmbier, who had been sentenced to 15 years in prison for trying to steal a propaganda poster, was released in a mysterious coma and died shortly afterwards.
That prompted Washington to slap a travel ban on American citizens.
About half of PUST’s 80-odd foreign faculty were Americans who have been unable to return for this academic year as a result, and it has filled the gaps with Chinese replacements.
It has also had problems transferring funds and importing materials due to the sanctions imposed on the North over its nuclear programme by the UN Security Council and others.
‘We do of course hope that this is a step in a positive process that will lead to the U.S. administration ending the travel ban on U.S. citizens,’ a school official told AFP, ‘so that many of our regular faculty and leadership can come back to the PUST campus and we can resume operations in a more normal way.’
On its website, PUST says it is hiring new faculty members: English and Chinese instructors, and professors for subjects ranging from stem cell culture technology to genetic engineering.
It does not mention the detention of its lecturers.
Korean-American writer Suki Kim went to PUST undercover as an English teacher in 2011 and later wrote a book about her experiences.
‘PUST offers a mutually beneficial arrangement for both North Korea and the evangelicals,’ she wrote in an essay published in the Washington Post last year following Tony Kim’s detention.
‘The regime gets free education for its youth and a modern facility… while the evangelicals get a footing in the remote nation,’ she said.
Source: AFP
http://www.dailymail.co.uk/news/article-5712509/Trump-Melania-meet-three-Americans-imprisoned-North-Korea-land-2am.html#ixzz5FE2k7Baj
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