The Pronk Pops Show 931, July 19, 2017, Story 1: “Obamacare Failed” Says President Trump — Wants Obamacare Completely  Repealed and Replaced Sooner or Later — Obama Lied To American People — Does President Trump Understand The Relationship Between Pre-existing Conditions, Guaranteed Issue, Community Rating and Adverse Selection — Many Doubt Trump Really Understands The Relationship That Is The Real Reason Obamacare Was Designed To Fail From The Beginning So It Could Be Replaced By Single Payer Government Health Care — Videos

Posted on July 20, 2017. Filed under: Abortion, Addiction, American History, Barack H. Obama, Biology, Blogroll, Breaking News, Bribery, Budgetary Policy, Business, Cartoons, Chemistry, Communications, Congress, Constitutional Law, Corruption, Countries, Crime, Culture, Diet, Diets, Disasters, Donald J. Trump, Donald J. Trump, Donald Trump, Donald Trump, Drugs, Economics, Education, Elections, Empires, Employment, Energy, Eugenics, Exercise, Fiscal Policy, Food, Food, Former President Barack Obama, Freedom of Speech, Government, Government Dependency, Government Spending, Health, Health Care, Health Care Insurance, Hillary Clinton, Hillary Clinton, Hillary Clinton, History, House of Representatives, Human, Human Behavior, Illegal Drugs, Immigration, Independence, Insurance, Investments, Labor Economics, Language, Law, Legal Drugs, Life, Lying, Media, Medical, Medicare, Medicine, Monetary Policy, National Interest, Networking, News, Obama, People, Philosophy, Photos, Politics, Polls, President Trump, Pro Abortion, Pro Life, Progressives, Radio, Rand Paul, Raymond Thomas Pronk, Regulation, Religion, Resources, Rule of Law, Scandals, Science, Security, Senate, Social Science, Social Security, Success, Tax Policy, Taxation, Taxes, Ted Cruz, United States Constitution, United States of America, Videos, Violence, Wealth, Welfare Spending, Wisdom | Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |

Project_1

The Pronk Pops Show Podcasts

Pronk Pops Show 931,  July 19, 2017

Pronk Pops Show 930,  July 18, 2017

Pronk Pops Show 929,  July 17, 2017

Pronk Pops Show 928,  July 13, 2017

Pronk Pops Show 927,  July 12, 2017

Pronk Pops Show 926,  July 11, 2017

Pronk Pops Show 925,  July 10, 2017

Pronk Pops Show 924,  July 6, 2017

Pronk Pops Show 923,  July 5, 2017

Pronk Pops Show 922,  July 3, 2017 

Pronk Pops Show 921,  June 29, 2017

Pronk Pops Show 920,  June 28, 2017

Pronk Pops Show 919,  June 27, 2017

Pronk Pops Show 918,  June 26, 2017 

Pronk Pops Show 917,  June 22, 2017

Pronk Pops Show 916,  June 21, 2017

Pronk Pops Show 915,  June 20, 2017

Pronk Pops Show 914,  June 19, 2017

Pronk Pops Show 913,  June 16, 2017

Pronk Pops Show 912,  June 15, 2017

Pronk Pops Show 911,  June 14, 2017

Pronk Pops Show 910,  June 13, 2017

Pronk Pops Show 909,  June 12, 2017

Pronk Pops Show 908,  June 9, 2017

Pronk Pops Show 907,  June 8, 2017

Pronk Pops Show 906,  June 7, 2017

Pronk Pops Show 905,  June 6, 2017

Pronk Pops Show 904,  June 5, 2017

Pronk Pops Show 903,  June 1, 2017

Pronk Pops Show 902,  May 31, 2017

Pronk Pops Show 901,  May 30, 2017

Pronk Pops Show 900,  May 25, 2017

Pronk Pops Show 899,  May 24, 2017

Pronk Pops Show 898,  May 23, 2017

Pronk Pops Show 897,  May 22, 2017

Pronk Pops Show 896,  May 18, 2017

Pronk Pops Show 895,  May 17, 2017

Pronk Pops Show 894,  May 16, 2017

Pronk Pops Show 893,  May 15, 2017

Pronk Pops Show 892,  May 12, 2017

Pronk Pops Show 891,  May 11, 2017

Pronk Pops Show 890,  May 10, 2017

Pronk Pops Show 889,  May 9, 2017

Pronk Pops Show 888,  May 8, 2017

Pronk Pops Show 887,  May 5, 2017

Pronk Pops Show 886,  May 4, 2017

Pronk Pops Show 885,  May 3, 2017

Pronk Pops Show 884,  May 1, 2017

Pronk Pops Show 883 April 28, 2017

Pronk Pops Show 882: April 27, 2017

Pronk Pops Show 881: April 26, 2017

Pronk Pops Show 880: April 25, 2017

Pronk Pops Show 879: April 24, 2017

Pronk Pops Show 878: April 21, 2017

Pronk Pops Show 877: April 20, 2017

Pronk Pops Show 876: April 19, 2017

Pronk Pops Show 875: April 18, 2017

Pronk Pops Show 874: April 17, 2017

Pronk Pops Show 873: April 13, 2017

Pronk Pops Show 872: April 12, 2017

Pronk Pops Show 871: April 11, 2017

Pronk Pops Show 870: April 10, 2017

Pronk Pops Show 869: April 7, 2017

Pronk Pops Show 868: April 6, 2017

Pronk Pops Show 867: April 5, 2017

Pronk Pops Show 866: April 3, 2017

Image result for cartoons trump on obamacare failure

Image result for cartoons trump on obamacare failure

Image result for cartoons Obamacare has failed

Image result for cartoons trump on obamacare failure

Image result for cartoons trump on obamacare failure

Image result for branco cartoons obamacare failed

Image result for cartoons trump on obamacare failure

 

Image result for Obamacare has failed

Image result for cartoons trump on obamacare failure

Story 1: “Obamacare Failed” Says President Trump — Wants Obamacare Completely  Repealed and Replaced Sooner or Later — Obama Lied To American People — Does President Trump Understand The Relationship Between Pre-existing Conditions, Guaranteed Issue, Community Rating and Adverse Selection — Many Doubt Trump Really Understands The Relationship That Is The Real Reason Obamacare Was Designed To Fail From The Beginning So It Could Be Replaced By Single Payer Government Health Care — Videos

Trump Warns GOP Senators; 7-19-2017

MUST WATCH: President Trump Reacts to GOP Healthcare Bill Collapse – “Let ObamaCare Fail” (FNN)

LIMBAUGH: If We REPEAL Obamacare, “It’s The WILD WEST”

Rand Paul on Failed Healthcare Bill | Repealing Obamacare

Sen. Rand Paul Still Wants a Clean Repeal of Obamacare

Senator Mike Lee: Trump is right. repeal Obamacare now, replace later

Richard Epstein: Obamacare’s Collapse, the 2016 Election, & More

Richard Epstein – Obama Explained

Health Care 2: Can Congress Force Individuals to Buy Insurance?

Richard Epstein on Health Care Reform

The Truth Behind the Affordable Care Act – Learn Liberty

Is Obamacare Working? The Affordable Care Act Five Years Later

Why Is Healthcare So Expensive?

Why Is U.S. Health Care So Expensive?

Milton Friedman on universal health care

Milton Friedman on Medical Care (Full Lecture)

Professor Richard Epstein tribute to Milton Friedman

Does Trump Even Know What A Pre-Existing Conditions Is??

Here’s Why the Epic Health Care Reform Disaster Occurred

Here’s Why the Epic Health Care Reform Disaster Occurred

Will I pay more for insurance if I have a pre-existing condition under Obamacare?

Hume: Trump’s scenario for ObamaCare ‘politically nuts’

Obama’s Health Plan In 4 Minutes

How ObamaCare has been a financial failure

We Now Have Proof Obamacare Was Designed to Fail… and Here’s Why

The Pronk Pops Show Podcasts Portfolio

Listen To Pronk Pops Podcast or Download Shows 926-931

Listen To Pronk Pops Podcast or Download Shows 916-925

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Listen To Pronk Pops Podcast or Download Shows 878-883

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Listen To Pronk Pops Podcast or Download Shows 827-832

Listen To Pronk Pops Podcast or Download Shows 821-826

Listen To Pronk Pops Podcast or Download Shows 815-820

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Listen To Pronk Pops Podcast or Download Shows 793-799

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Listen To Pronk Pops Podcast or Download Shows 556-564

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Listen To Pronk Pops Podcast or Download Shows 538-545

Listen To Pronk Pops Podcast or Download Shows 532-537

Listen To Pronk Pops Podcast or Download Shows 526-531

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Listen To Pronk Pops Podcast or Download Shows 473-479

Listen To Pronk Pops Podcast or Download Shows 464-472

Listen To Pronk Pops Podcast or Download Shows 455-463

Listen To Pronk Pops Podcast or Download Shows 447-454

Listen To Pronk Pops Podcast or Download Shows 439-446

Listen To Pronk Pops Podcast or Download Shows 431-438

Listen To Pronk Pops Podcast or Download Shows 422-430

Listen To Pronk Pops Podcast or Download Shows 414-421

Listen To Pronk Pops Podcast or Download Shows 408-413

Listen To Pronk Pops Podcast or Download Shows 400-407

Listen To Pronk Pops Podcast or Download Shows 391-399

Listen To Pronk Pops Podcast or Download Shows 383-390

Listen To Pronk Pops Podcast or Download Shows 376-382

Listen To Pronk Pops Podcast or Download Shows 369-375

Listen To Pronk Pops Podcast or Download Shows 360-368

Listen To Pronk Pops Podcast or Download Shows 354-359

Listen To Pronk Pops Podcast or Download Shows 346-353

Listen To Pronk Pops Podcast or Download Shows 338-345

Listen To Pronk Pops Podcast or Download Shows 328-337

Listen To Pronk Pops Podcast or Download Shows 319-327

Listen To Pronk Pops Podcast or Download Shows 307-318

Listen To Pronk Pops Podcast or Download Shows 296-306

Listen To Pronk Pops Podcast or Download Shows 287-295

Listen To Pronk Pops Podcast or Download Shows 277-286

Listen To Pronk Pops Podcast or Download Shows 264-276

Listen To Pronk Pops Podcast or Download Shows 250-263

Listen To Pronk Pops Podcast or Download Shows 236-249

Listen To Pronk Pops Podcast or Download Shows 222-235

Listen To Pronk Pops Podcast or Download Shows 211-221

Listen To Pronk Pops Podcast or Download Shows 202-210

Listen To Pronk Pops Podcast or Download Shows 194-201

Listen To Pronk Pops Podcast or Download Shows 184-193

Listen To Pronk Pops Podcast or Download Shows 174-183

Listen To Pronk Pops Podcast or Download Shows 165-173

Listen To Pronk Pops Podcast or Download Shows 158-164

Listen To Pronk Pops Podcast or Download Shows151-157

Listen To Pronk Pops Podcast or Download Shows 143-150

Listen To Pronk Pops Podcast or Download Shows 135-142

Listen To Pronk Pops Podcast or Download Shows 131-134

Listen To Pronk Pops Podcast or Download Shows 124-130

Listen To Pronk Pops Podcast or Download Shows 121-123

Listen To Pronk Pops Podcast or Download Shows 118-120

Listen To Pronk Pops Podcast or Download Shows 113 -117

Listen To Pronk Pops Podcast or Download Show 112

Listen To Pronk Pops Podcast or Download Shows 108-111

Listen To Pronk Pops Podcast or Download Shows 106-108

Listen To Pronk Pops Podcast or Download Shows 104-105

Listen To Pronk Pops Podcast or Download Shows 101-103

Listen To Pronk Pops Podcast or Download Shows 98-100

Listen To Pronk Pops Podcast or Download Shows 94-97

Listen To Pronk Pops Podcast or Download Show 93

Listen To Pronk Pops Podcast or Download Show 92

Listen To Pronk Pops Podcast or Download Show 91

Listen To Pronk Pops Podcast or Download Shows 88-90

Listen To Pronk Pops Podcast or Download Shows 84-87

Listen To Pronk Pops Podcast or Download Shows 79-83

Listen To Pronk Pops Podcast or Download Shows 74-78

Listen To Pronk Pops Podcast or Download Shows 71-73

Listen To Pronk Pops Podcast or Download Shows 68-70

Listen To Pronk Pops Podcast or Download Shows 65-67

Listen To Pronk Pops Podcast or Download Shows 62-64

Listen To Pronk Pops Podcast or Download Shows 58-61

Listen To Pronk Pops Podcast or Download Shows 55-57

Listen To Pronk Pops Podcast or Download Shows 52-54

Listen To Pronk Pops Podcast or Download Shows 49-51

Listen To Pronk Pops Podcast or Download Shows 45-48

Listen To Pronk Pops Podcast or Download Shows 41-44

Listen To Pronk Pops Podcast or Download Shows 38-40

Listen To Pronk Pops Podcast or Download Shows 34-37

Listen To Pronk Pops Podcast or Download Shows 30-33

Listen To Pronk Pops Podcast or Download Shows 27-29

Listen To Pronk Pops Podcast or Download Shows 17-26

Listen To Pronk Pops Podcast or Download Shows 16-22

Listen To Pronk Pops Podcast or Download Shows 10-15

Listen To Pronk Pops Podcast or Download Shows 1-9

 

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The Pronk Pops Show 919, June 27, 2017, Part 1 — Story 1: Breaking BIG — Big Interventionist Government — Obamacare and Obamacare Lite — The Progressive Two-Party Tyranny of The Democratic and Republican Parties — Fake Repeal and Fake Replace Is Not Real Repeal of Obamacare and All Obamacare Regulations and Replace With Free Enterprise Individual Health Insurance Markets Not Centralized Federal Control and Regulation with Massive Subsidies Of Health Insurance Industry — Collectivists vs Individualists — Replace The C, D, F BIG Progressive Republican Senators and Representatives — The Party’s Over — Videos

Posted on June 27, 2017. Filed under: American History, Breaking News, Budgetary Policy, Communications, Countries, Defense Spending, Donald J. Trump, Donald J. Trump, Donald Trump, Economics, Education, Elections, Employment, Fiscal Policy, Freedom of Speech, Government, Government Dependency, Government Spending, Health, Health Care Insurance, History, Human, Labor Economics, Law, Life, Media, Medicare, Monetary Policy, News, People, Philosophy, Photos, Politics, Polls, President Barack Obama, President Trump, Pro Life, Progressives, Raymond Thomas Pronk, Regulation, Rule of Law, Scandals, Security, Social Security, Success, Tax Policy, Taxation, Taxes, Terror, Terrorism, Unemployment, United States Constitution, United States of America, Videos, Wealth, Wisdom | Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |

Project_1

The Pronk Pops Show Podcasts

Pronk Pops Show 919,  June 27, 2017

Pronk Pops Show 918,  June 26, 2017 

Pronk Pops Show 917,  June 22, 2017

Pronk Pops Show 916,  June 21, 2017

Pronk Pops Show 915,  June 20, 2017

Pronk Pops Show 914,  June 19, 2017

Pronk Pops Show 913,  June 16, 2017

Pronk Pops Show 912,  June 15, 2017

Pronk Pops Show 911,  June 14, 2017

Pronk Pops Show 910,  June 13, 2017

Pronk Pops Show 909,  June 12, 2017

Pronk Pops Show 908,  June 9, 2017

Pronk Pops Show 907,  June 8, 2017

Pronk Pops Show 906,  June 7, 2017

Pronk Pops Show 905,  June 6, 2017

Pronk Pops Show 904,  June 5, 2017

Pronk Pops Show 903,  June 1, 2017

Pronk Pops Show 902,  May 31, 2017

Pronk Pops Show 901,  May 30, 2017

Pronk Pops Show 900,  May 25, 2017

Pronk Pops Show 899,  May 24, 2017

Pronk Pops Show 898,  May 23, 2017

Pronk Pops Show 897,  May 22, 2017

Pronk Pops Show 896,  May 18, 2017

Pronk Pops Show 895,  May 17, 2017

Pronk Pops Show 894,  May 16, 2017

Pronk Pops Show 893,  May 15, 2017

Pronk Pops Show 892,  May 12, 2017

Pronk Pops Show 891,  May 11, 2017

Pronk Pops Show 890,  May 10, 2017

Pronk Pops Show 889,  May 9, 2017

Pronk Pops Show 888,  May 8, 2017

Pronk Pops Show 887,  May 5, 2017

Pronk Pops Show 886,  May 4, 2017

Pronk Pops Show 885,  May 3, 2017

Pronk Pops Show 884,  May 1, 2017

Pronk Pops Show 883 April 28, 2017

Pronk Pops Show 882: April 27, 2017

Pronk Pops Show 881: April 26, 2017

Pronk Pops Show 880: April 25, 2017

Pronk Pops Show 879: April 24, 2017

Pronk Pops Show 878: April 21, 2017

Pronk Pops Show 877: April 20, 2017

Pronk Pops Show 876: April 19, 2017

Pronk Pops Show 875: April 18, 2017

Pronk Pops Show 874: April 17, 2017

Pronk Pops Show 873: April 13, 2017

Pronk Pops Show 872: April 12, 2017

Pronk Pops Show 871: April 11, 2017

Pronk Pops Show 870: April 10, 2017

Pronk Pops Show 869: April 7, 2017

Pronk Pops Show 868: April 6, 2017

Pronk Pops Show 867: April 5, 2017

Pronk Pops Show 866: April 3, 2017

Pronk Pops Show 865: March 31, 2017

Pronk Pops Show 864: March 30, 2017

Pronk Pops Show 863: March 29, 2017

Pronk Pops Show 862: March 28, 2017

Pronk Pops Show 861: March 27, 2017

Pronk Pops Show 860: March 24, 2017

Pronk Pops Show 859: March 23, 2017

Pronk Pops Show 858: March 22, 2017

Pronk Pops Show 857: March 21, 2017

Pronk Pops Show 856: March 20, 2017

Pronk Pops Show 855: March 10, 2017

Pronk Pops Show 854: March 9, 2017

Pronk Pops Show 853: March 8, 2017

Pronk Pops Show 852: March 6, 2017

Pronk Pops Show 851: March 3, 2017

Pronk Pops Show 850: March 2, 2017

Pronk Pops Show 849: March 1, 2017

Image result for cartoons on repeal and replace of obamacare

Image result for Progressive republicans and democrats the two party tyrannyImage result for cartoons on repeal and replace of obamacareImage result for Progressive republicans and democrats the two party tyranny

National Debt Clock 

http://www.usdebtclock.org/

Image result for Progressive republicans and democrats the two party tyranny

Part 1 — Story 1: Breaking BIG — Big Interventionist Government — Obamacare and Obamacare Lite — The Progressive Two-Party Tyranny of The Democratic and Republican Parties — Fake Repeal and Fake Replace Is Not Real Repeal of Obamacare and All Obamacare Regulations and Replace With Free Enterprise Individual Health Insurance Markets Not Centralized Federal Control and Regulation with Massive Subsidies Of Health Insurance Industry — Collectivists vs Individualists — Replace The C, D, F BIG Progressive Republican Senators, and Representatives — The Party’s Over — Videos

 

Image result for Per capita health care expenditures by country 2015

Image result for Per capita health care expenditures by country 2015

 

Image result for Per capita health care expenditures by country 2015

Image result for Per capita health care expenditures by country 2015

Image result for Per capita health care expenditures by country 2015

Image result for how many americans are in employer paid health insurance v. individual health insurance

Judy Holliday – The Party’s Over

Judy Holliday The Party’s Over Lyrics

The party’s over
It’s time to call it a day
They’ve burst your pretty balloon
And taken the moon away.

It’s time to wind up

The masquerade
Just make your mind up
The piper must be paid.

The party’s over
The candles flicker and dim
You danced and dreamed

Through the night
It seemed to be right
Just being with him.

Now you must wake up
All dreams must end
Take off your makeup

The party’s over
It’s all over, my friend.

Now you must wake up
All dreams must end
Take off your makeup
The party’s over
It’s all over, my friend.

President Trump Holds Meeting with GOP Senators After Delayed Healthcare Vote 6/27/17

I won’t vote to keep ObamaCare: Rand Paul

What is President Trump’s role in the health care fight?

MARK LEVIN: Senate Health Care Bill Is 95% OBAMACARE

Conservative George Will MOCKS Donald Trump And Derives Republicans Over Hypocrisy On Trumpcare

Sen. Rand Paul: Our Bill May Cost More In First 2 Years Than Obamacare Did | TODAY

Republicans delay Senate health care vote

Heller says he will not support the GOP Senate health-care bill

Senator Ron Johnson: ‘We Should Not Be Voting’ on Healthcare This Week | Meet The Press | MSNBC

Milton Friedman – Collectivism

Milton Friedman on universal health care

Milton Friedman – The Social Security Myth

Milton Friedman – The Welfare Establishment

Milton Friedman – Tyranny of the Status Quo – Part 1 – Beneficiaries

Milton Friedman – Tyranny of the Status Quo – Part 2 – Bureaucrats

Milton Friedman – Tyranny of the Status Quo – Part 3 – Politicians

Milton Friedman – Why Tax Reform Is Impossible

Milton Friedman – Health Care Reform (1992) pt 1/4

Milton Friedman – Health Care Reform (1992) pt 2/4

Milton Friedman – Health Care Reform (1992) pt 3/4

Milton Friedman – Health Care Reform (1992) pt 3/4

Milton Friedman – Health Care Reform (1992) pt 4/4

Milton Friedman – Morality & Capitalism

Lacking enough GOP votes, Senate pushes back health bill

Sen. Rand Paul: Senate health care bill needs more Obamacare ‘repeal’

Hardball with Chris Matthews 6/27/17 Republicans can’t repeal and replace Obamacare

Hume on GOP Health Care Fight: Either Way, Republicans Have a ‘Problem’

Rand Paul: Let’s Repeal Obamacare And Don’t Replace It

Rush Limbaugh Talks Obamacare With VP Mike Pence: “We Take The Teeth Out Of The Tiger”

Republicans have one major problem on Obamacare

Why Can’t America Have a Grown-Up Healthcare Conversation?

Is Obamacare Working? The Affordable Care Act Five Years Later

Why Are American Health Care Costs So High?

How Health Insurance Works

Senate postpones health care bill vote

Individual Health Insurance VS. Group Health Insurance

Published on Aug 14, 2009

Ok so lets contrast individual vs. group health insurance. One thing that a lot of people get wrong is individual health insurance, number one isn’t as good coverage and number two, cost more than a group coverage. Well, these two things are wrong. The first one, lets talk about cost. We find that individual health insurance is about 40% less than any group plan. You can load it up with all the features and benefits you are looking for in a group

Group vs. Individual Health Insurance: Health Insurance Facts & More

Published on Aug 16, 2012

Trump triumphs, CNN implodes, the Russian myth is destroyed and the Alt-Left Media haven’t a clue.

How Demented and Sick Our Republic Has Become By Design

‘We’re Amending Obamacare. We’re Not Killing It’

The Senate bill coming out Thursday would do many things to health care in the U.S., but it won’t get rid of the Affordable Care Act, and Mitch McConnell won’t claim that it does.

The health-care bill Senate Republicans plan to unveil on Thursday likely will make substantial changes to Medicaid and cut taxes for wealthy Americans and businesses. It will eliminate mandates and relax regulations on insurance plans, and it will reduce the federal government’s role in health care.

What it won’t do, however, is actually repeal the Affordable Care Act.

Lost in the roiling debate over health care over the last several weeks is that Republicans have all but given up on their longstanding repeal-and-replace pledge. The slogan lives on in the rhetoric used by many GOP lawmakers and the Trump White House but not in the legislation the party is advancing. That was true when House Republicans passed the American Health Care Act last month, which rolled back key parts of Obamacare but was not a full repeal. And it is even more true of the bill the Senate has drafted in secret, which reportedly will stick closer to the underlying structure of the law.

“We’re amending Obamacare. We’re not killing it,” a frustrated Jason Pye of the conservative group FreedomWorks told me earlier this month as the murky outlines of the Senate proposal were beginning to emerge.

Like the House bill, the Senate plan is expected to repeal the ACA’s employer and individual insurance mandates and most if not all of the tax increases Democrats levied to pay for new programs and benefits. But the Senate bill likely will only begin a years-long phase-out of the ACA’s Medicaid expansion in 2020 rather than end it as the House measure does.

The Senate also is expected to include more generous tax credits than the House bill that more closely resemble the system already in place under Obamacare. But the funding levels would still be lower than the current law. And according to Axios, the bill would allow states to opt out of some ACA insurance regulations, but it would do so by loosening existing waivers within the current law rather than follow the House in creating a new waiver system. And the Senate proposal would require that states adhere to more of Obamacare’s regulations than the House bill.Senate Majority Leader McConnell has quietly abandoned the language of “repeal-and-replace” that his office originated seven years ago in the immediate aftermath of the ACA’s enactment. In more than a dozen speeches on health care that McConnell has delivered on the Senate floor since the House passed its bill in early May, he hasn’t uttered the word “repeal” a single time, according to transcripts provided by the majority leader’s office. Nor has he repeated his own pledge to rip out Obamacare “root and branch.” “We’re going to make every effort to pass a bill that dramatically changes the current health care law,” McConnell told reporters on Tuesday, setting a new standard for the bill Republicans plan to release on Thursday.

When the year started, legislation leaving Obamacare substantially in place would have been dead on arrival with hardliners in the House and Senate, who demanded that party leaders expand on a bill that former President Barack Obama vetoed in 2015. That measure did not fully repeal the ACA either, bowing to Senate budget rules limiting how much of the law Republicans could scrap without a filibuster-proof 60 votes. But it eliminated the tax credits and subsidies undergirding the law’s insurance exchanges along with its tax increases and mandates. And with Republicans now in control of both Congress and the White House, conservatives in the House Freedom Caucus this spring began pushing the leadership to go further by repealing Obamacare’s core consumer protections guaranteeing the coverage of essential health benefits and prohibiting insurers from charging higher rates to people with preexisting conditions.

The deal that ultimately allowed the AHCA to pass the House was an under-appreciated turning point in the health-care debate. The concession that Speaker Paul Ryan and a few key moderates made to the Freedom Caucus was to allow states to opt out of some of Obamacare’s insurance regulations, most crucially on equal treatment for pre-existing conditions. But the concession that conservative lawmakers and outside groups made in return was just as significant: They agreed to back off their demand for full repeal and endorse—or at least not fight—a bill that fell far short of that goal.“While this legislation does not fully repeal Obamacare, it’s an important step in keeping that promise to lower healthcare costs,” the Freedom Caucus said in its statement upon passage of the AHCA. It was a message echoed by outside groups like FreedomWorks, Heritage Action, and the Club for Growth, who agreed to drop their opposition to the bill, a move that gave Republicans additional cover to vote for it. Conservatives had embraced an incrementalist approach to Obamacare. The new standard they adopted for health-care legislation was not whether it eliminated the Affordable Care Act but whether it would lower premiums for most consumers.One key question for McConnell is whether the most outspoken conservatives in his caucus—Senators Rand Paul of Kentucky, Ted Cruz of Texas, and Mike Lee of Utah—will judge the Senate bill by that more modest baseline. Republicans can lose no more than two votes to secure passage, and a group of moderate senators is proving just as difficult for party leaders to nail down. To this point, Paul has been the most critical of the GOP approach and the most likely to oppose the proposal from the right. The House bill, he complained, already kept 90 percent of Obamacare’s subsidies. “If this gets any more subsidies in it, it may well be equal to what we have in Obamacare. So it really wouldn’t be repeal,” Paul said on Tuesday, according to Bloomberg. Even so, the Kentucky conservative wouldn’t rule out supporting the bill until he read the text.Cruz and Lee have participated in the Senate process as members of the 13-man working group, and aides have said both have bought into McConnell’s incremental approach. But the two have each complained about the emerging draft in recent days, either on the substance or the top-down, secretive process used to write the bill. “We’re not there yet,” Cruz said Tuesday on Fox News. “The current draft doesn’t do nearly enough to lower premiums.”The Congressional Budget Office projected that in states that opted out of Obamacare’s insurance requirements under the waivers allowed in the House bill, average premiums would drop significantly. But the tradeoff is that people with preexisting conditions would face sharply higher costs or be priced out of insurance entirely. Conservatives have argued that the high cost of adhering to the ACA’s minimum coverage requirements has forced insurers to raise premiums in order to make a profit.Conservative activists briefly held out hope that the health-care bill would move further to the right in the Senate, buoyed by efforts by Cruz and Lee to have Republicans override parliamentary rulings limiting how much of Obamacare they could repeal through the budget reconciliation process. But party leaders never seriously considered that option, which moderate Republicans were likely to oppose.In recent weeks, conservatives have instead focused on demanding that the Senate preserve—or deepen—the reforms to Medicaid in the House bill while still repealing all of Obamacare’s tax hikes. “It is clear that significant portions of the Republican Party have no intention of actually repealing Obamacare despite campaigning on that objective for years,” Mike Needham, CEO of Heritage Action, said in a statement on Wednesday.

“Conservatives will evaluate legislative language when it becomes available, looking particularly at whether the legislation empowers states to get out of the onerous insurance mandates imposed by Obamacare, maintains and improves the House’s Medicaid reforms, and repeals Obamacare’s stifling taxes.”

Make no mistake, Republicans aren’t merely tinkering around the edges of the health-care system, or Obamacare. The Senate proposal that will come out on Thursday will significantly alter the federal funding of Medicaid and, in all likelihood, would result in millions fewer Americans having health insurance over the next decade, as projected by the CBO. And while they won’t be excited by the bill, conservative senators and activists might well come around to support it. They’d vote for the plan as a step in the right direction, a weakening of Obamacare. But like McConnell, they won’t be calling it something that it’s not: repeal.

https://www.theatlantic.com/politics/archive/2017/06/senate-republican-bill-obamacare-repeal/531108/

What’s in the Senate Republican Health-Care Bill

Like the House version, Mitch McConnell’s proposal would slash taxes, cut Medicaid, and eliminate Obamacare’s insurance mandates for individuals and employers.

The Senate Republican health-care bill is finally out in the open.

After weeks of secretive deliberations, party leaders on Thursday released a 142-page proposal that would slash taxes on the wealthy and businesses; reduce federal funding for Medicaid and phase out its expansion under the Affordable Care Act; and limit the tax credits available to help people purchase insurance on the individual market. The legislation, titled the Better Care Reconciliation Act of 2017, is officially labeled a “discussion draft,” but Senate Majority Leader Mitch McConnell wants Republicans to debate and vote on the bill by the end of next week.

Like the American Health Care Act that passed the House in May, the Senate bill is a substantial revision to Obamacare but not a wholesale repeal. And while Senate Republicans had vowed to start over rather than work off the unpopular House proposal, their version is structured the same way. The Senate measure mirrors the House bill in eliminating the ACA’s employer and individual insurance mandates and most of the tax increases it imposed to pay for new programs. Both proposals call for an overhaul of Medicaid funding that would allow states to institute work requirements and end the program’s status as an open-ended entitlement. The Senate bill would go further than the House’s $800 billion in cuts by reducing its growth rate beginning in 2025, but unlike the House version, it would begin a three-year phase-out of the program’s expansion in 2020. The AHCA would cut off the expansion entirely that year.

As expected, Democrats assailed the proposal as a draconian measure that would strip health insurance from millions all for the goal of providing tax cuts for the rich. They seized on comments that President Trump reportedly made to Republican senators in which he called the House proposal “mean.”
“Simply put: This bill will result in higher costs, less care, and millions of Americans will lose their health insurance, particularly through Medicaid,” Senate Minority Leader Charles Schumer said. “It’s every bit as bad as the House bill; in some ways, it’s even worse.”

But the McConnell was never intended to appeal to Democrats. Instead, the majority leader and the Senate policy staffers who wrote the bill were trying to strike a delicate balance between conservatives bent on ripping up Obamacare and moderate Republican senators who, though they campaigned on repeal, now want to preserve its central benefits. Whether McConnell achieved that middle ground is unclear, as few Republican senators leapt to embrace his proposal in the immediate aftermath of its release. The first official holdouts to emerge were a group of four conservatives: Senators Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah, and Ron Johnson of Wisconsin.“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” they said in a joint statement. “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”Their statement was significant because together, their opposition alone could sink the bill given the GOP’s narrow, 52-48 majority in the Senate. But its careful wording left a lot of room for any or all of the conservatives to come around by the time the bill hits the floor next week. Paul, who has been a critic of the GOP approach for months, was more harsh in a pair of tweets he sent on his own. “The current bill does not repeal Obamacare. It does not keep our promises to the American people,” he wrote. Paul had long been considered a likely no vote, as it is unlikely McConnell could move the bill far enough to the right to get his support without losing moderates.
The draft will also face the test of whether its provisions pass muster under the Senate’s complex rules for budget reconciliation, which would allow Republican to circumvent a Democratic filibuster. Aides on Thursday acknowledged that “there will be ongoing discussions with the Parliamentarian” in the Senate about certain parts of the bill.The Senate proposal targets abortion coverage by prohibiting the use of tax credits to buy insurance plans that cover the procedure, and it would ban funds from going to Planned Parenthood. Those provisions could jeopardize the support of two moderate Republicans, Senators Susan Collins of Maine and Lisa Murkowski of Alaska, who have said they oppose restricting federal funding to Planned Parenthood. A spokeswoman for Collins, Annie Clark, said Thursday she would be reviewing the bill into the weekend. “She has a number of concerns and will be particularly interested in examining the forthcoming CBO analysis on the impact on insurance coverage, the effect on insurance premiums, and the changes in the Medicaid program,” Clark said.The Senate bill also allows states to opt out of some of Obamacare’s insurance regulations, but it does not allow waivers that would let insurance companies charge higher rates to people with preexisting conditions. “We’re not touching preexisting conditions,” one top GOP staffer told reporters on a Thursday conference call. While the House bill created a new waiver system aimed at allowing states to get around Obamacare requirements, the Senate expands an existing waiver in the current law to make it easier for states to apply. The provision, aides said, would allow insurance companies in states that obtain waivers to sell plans that do not provide essential health benefits, including maternity care, hospitalization, and mental-health treatment.Unlike the House bill, the Senate proposal contains funding for cost-sharing payments for insurers to help stabilize the faltering individual insurance market under Obamacare. They would continue through 2019 before being repealed entirely. The payments are the subject of a lawsuit that House Republicans filed against the Obama administration three years ago, and while the Trump administration has continued the subsidies, its refusal to guarantee them over the long term has prompted more insurers to exit the ACA exchanges.McConnell has drawn criticism from senators in both parties for writing the bill behind closed doors without public hearings, though it’s unclear if the mounting frustration among some Republican senators about the process will threaten the legislation’s passage. In a floor speech on Thursday morning, the majority leader said senators would have “ample time” to review and amend the bill before a final vote. The Congressional Budget Office said it would release its analysis of the Senate bill’s cost and impact on insurance early next week. It found that the House bill would leave 23 million more people uninsured over the next decade while reducing average premiums depending on whether states opted out of Obamacare’s insurance regulations.“We debated many policy proposals. We considered many different viewpoints,” McConnell said. “In the end, we found that we share many ideas about what needs to be achieved and how we can achieve it. These shared policy objectives and the solutions to help achieve them are what make up the health care discussion draft that we talked through this morning.”Senate budget rules call for what’s known as a “vote-a-rama” where members of either party offer amendments in a single session. And in many ways, it appears McConnell’s draft is designed to be amended. The bill, for example, does not include funding for the opioid crisis that Senators Rob Portman of Ohio, Shelley Moore Capito of West Virginia, and others were demanding. Nor does it adopt their proposal for a longer, seven-year phase-out of the Medicaid expansion. But by omitting those provisions at the front end, McConnell could be inviting Portman, Capito, and other wavering senators to add them by amendment so they can claim credit for improving the bill when it comes to the floor. Similarly, the statement Paul, Cruz, Lee, and Johnson appeared to be a play for changes that could win their ultimate support.Republicans have a razor-thin majority of 52 seats, and McConnell can lose no more than two votes to pass the bill with a tie-breaker from Vice President Mike Pence. The majority leader will also face difficulty securing support from conservatives who feel the proposal doesn’t go far enough in dismantling Obamacare.https://www.theatlantic.com/politics/archive/2017/06/whats-in-the-senate-republican-health-care-bill/531258/
Mark Levin’s new book, “Rediscovering Americanism,” an assault on the media and progressives and a call for Americans to take back their country, debuts today at No. 1 on Amazon.

Showing the draw of the New York Times bestselling author and top syndicated radio host, his book is already on the way to becoming another big seller.

“My new book covers a lot of territory — philosophy, history, economics, law, culture, etc. And I look deeply into what is meant by Americanism, republicanism, individualism, capitalism. What do we mean by natural law, unalienable rights, liberty, and property rights? From where do these principles come? Why are they important?” he told Secrets.

It follows in the path of his other books and the nation: Liberty and Tyranny: A Conservative Manifesto; Ameritopia: The Unmaking of America; The Liberty Amendments; and Plunder and Deceit.

Secrets reviewed “Rediscovering Americanism”last week and wrote:

In the book, Levin attacks the embrace by the media, politicians, and academia of progressive promises of a “utopia” defined by the end of personal freedom and individuality.

He has a grim name for it: “The Final Outcome.” Levin wrote, “They reject history’s lessons and instead are absorbed with their own conceit and aggrandizement in the relentless pursuit of a diabolical project, the final outcome of which is an oppression of mind and soul.”

Levin added, “the equality they envision but dare not honestly proclaim, is life on the hamster wheel, where one individual is indistinguishable from the next.”

Paul Bedard, the Washington Examiner’s “Washington Secrets” columnist, can be contacted at pbedard@washingtonexaminer.com

http://www.washingtonexaminer.com/mark-levin-book-condemning-media-progressives-debuts-no-1-amazon/article/2627178

Dems face identity crisis

Democrats are grappling with how to keep their progressive base happy while winning over white working-class voters who left the party in the 2016 elections.

Defections by blue-collar voters cost Democrat Hillary Clinton the states of Michigan, Pennsylvania and Wisconsin, all of which went to President Trump. It was the first time since 1988 that a GOP presidential candidate had won Michigan or Pennsylvania, and the first time since 1984 in Wisconsin.

The fallout has created an identity crisis for a Democratic Party seeking to find its way forward in the post-Obama era.

A string of House special election losses culminating in Democrat Jon Ossoff’s disappointing defeat in Georgia last week has only intensified the scrutiny and second-guessing of Democratic strategy, to say nothing of the hand-wringing by party activists craving a victory.

“I’m not convinced we know what the best thing is for the party right now,” said Democratic strategist Jim Manley. “I’m not convinced we have the answers.”

Democrats trying to figure out what they’re doing wrong are focused on how they’ve seemingly lost a significant part of the Democratic base all while failing to turn out enough progressives.

There are different views about what to do across the party, with some questioning whether the white working-class voters can be won back by a party that seems to be tilting leftward with the rise of Sen. Bernie Sanders(I-Vt.) and other liberal voices.

“I’ve spoken to some folks who think we have to only choose one or the other,” said one former senior aide to President Barack Obama. “And after this election cycle, I think there are some who believe there may be some truth to that.”

A lot depends on whether the party can find the right candidate with the right message, particularly in 2020.

“Democrats need a reason for showing up. Give them a reason to believe, and we won’t be having this discussion,” the former Obama aide said.

Democrats say there is a way to appeal to both progressives and white working-class voters.

“Everybody is being too simplistic,” Democratic strategist Jamal Simmons said. “Voters are much more complex.”

Simmons said it’s not a matter of choosing to talk about police violence and climate change or the minimum wage and creating jobs.

Progressives, he said, want Democrats to talk about all of that.

They “want politicians to say something about Black Lives Matter and equality — they also want to know how they’re going to get their kids through college, pay off their house and get a better job,” he said. “The thing that’s most frustrating to me is this either-or dichotomy.”

Obama’s victories in 2008 and 2012 show Democrats can win over both groups, say some Democrats.

“This crisis is Democrats not realizing their own strengths, or being scared of articulating their core principles, rather than a crisis of having no agenda,” said Julian Zelizer, a professor of history and public affairs at Princeton University.

He said a focus on economics, climate change and being anti-Trump would animate the party.

“These are the places that 2018 candidates need to focus on, because they are ways to distinguish themselves from the GOP and its agenda,” he added. “Then they should continue to use Trump as a unifying theme. Often experts downplay this, but Republicans were very effective at using Obama that way.”

In recent days, particularly since the Ossoff loss, Democrats have been doing a lot of finger-pointing.

There’s been a movement to stop blaming the 2016 presidential election loss on Russia. And there have been calls to cut ties with current Democratic leaders like House Minority Leader Nancy Pelosi (D-Calif.). Some of those calls, within the House, come from lawmakers such as Rep. Tim Ryan (D-Ohio), who is worried about losing the white working class.

On the other end of the spectrum, some say Sanders’s bashing of Democrats has only deepened wounds.

“A lot of people are sick of it,” said Manley, a former adviser to then-Senate Majority Leader Harry Reid (D-Nev.). “The mainstream part of the party has had it up to here with what he’s been saying.”

Some Democrats are seeking to build a bridge between the two groups.

In an interview Sunday on ABC’s “This Week,” Senate Minority Leader Charles Schumer (D-N.Y.) said the party will unveil a “strong, bold, sharp-edged and commonsense economic agenda” in the coming weeks.

Addressing both wings of his party, he added, “I’m talking to Bernie Sanders. I’m talking to Joe Manchin. This is going to be really something that Democrats can be proud of, and I’m excited about it.”

Manchin, a Democratic senator from West Virginia, is among the most centrist members of Schumer’s conference.

Michael Tyler, a spokesman for the Democratic National Committee, said Democrats will look to expand their support across the party.

He acknowledged in an email to The Hill that in order to win elections, Democrats “have to focus on broadening and turning out our base and on reaching out to Americans who cast ballots for Donald Trump or didn’t vote at all.”

Tyler said Democrats are in the process of rebuilding a party “from an organization whose mission was solely to elect the president of the United States to one that organizes to elect Democrats up and down the ballot, from school board to Senate.”

But it may not be as easy as that, some strategists say.

Asked how the party rebounds and lures both working-class and progressive Democrats, Manley admitted: “I don’t have the faintest idea in this point in time. I’m still trying to digest what happened.”

http://thehill.com/homenews/campaign/339577-dems-face-identity-crisis

Replacing Obamacare is a make-or-break moment for Republicans

 June 25

Sen. Dean Heller (R-Nev.) threw himself off a political cliff last week when he declared full-throated opposition to the Senate version of the Obamacare repeal bill, and it remains to be seen if Heller is hanging by a limb out of sight and can climb back to electoral sanity or has hit rock bottom in his public career.Individual Senate Republicans face different political realities, but the caucus must somehow get the votes necessary to return the revised Obamacare “repeal and replace” bill to the House. To fail to do so is to condemn not only Heller and Arizona’s Sen. Jeff Flake to certain doom but probably others among the eight GOP senators up for reelection. The grass roots’ disgust with this betrayal will be so deep as to endanger every senator, even in deep red states such as Mississippi, Texas and Utah.The political crosswinds and upheavals in the country are already beyond predicting anything, so to add even more cause for grievance by betraying the central promise of the congressional GOP is beyond irresponsible. It is political insanity. Shut the door to the consultants, and throw out the polling senators. If the GOP defaults on its core promise, it is doomed as a party to minority status, probably as early as 2018 and certainly in 2020.

To fail this week almost certainly forfeits the House majority in next year’s midterm elections but perhaps also the Senate’s, and with the latter, the ability to confirm Supreme Court justices and lower court judges, pass budgets under reconciliation, have any chance at serious tax reform and of course approve the crucial repeal of the Defense Department sequestration.

This is of course an imperative vote on saving American health care. Next year, for example, there potentially will be at least 18 counties in Ohio without even a single option for an individuals seeking coverage. The swaths of America where there is only one provider are large and growing. “Choice for consumers” is a delusion, and soaring deductibles have made health care an illusion to millions more.

Obamacare is a catastrophe on its own terms, but the consequences of not passing its repeal are worse even beyond those awful health-care outcomes. It will forfeit every other Republican goal because failing to deliver on the central promise of eight years of debates and campaigns will shatter the credibility every Republican, not just those who block the bill. The party as a whole will be gravely wounded, perhaps beyond healing for a generation or more.

I don’t have to guess about this. I have been talking to the center-right of the country for three hours a day Monday through Friday for the past 17 years. I know the central argument of the conservative activists everywhere in the United States is that Beltway Republicans cannot be trusted to do anything hard. That argument was dented by the discipline with which the GOP put up with the mainstream media and Democrats’ slings and arrows in the fight over replacing Justice Antonin Scalia. Majority Leader Mitch McConnell (Ky.) rightly calculated that to surrender that hill would be to lose not just a political battle but the political war stretching long into the future. It was that big of a deal to the base.

The same is true of Obamacare. To vote “no” on whatever compromise arrives is to express contempt for the Republican Party as a whole – and its grass-roots activists and base voters — and for those ideas it stands for on all major matters, from a strong defense to low taxes to an originalist Supreme Court.

Thus Heller seemed to declare himself a hollow man when he said he could not vote for it, a man without any core beliefs because with his rambling statement he endangered all alleged core GOP beliefs, and thus the GOP will not support him. It isn’t about primaries; primary opponents need not materialize. It is about millions of conservatives who will simply give up on politics.

This is a make-or-break moment for Senate Republicans and the party itself. Sadly, for this conservative, the tone-deafness of Heller may not be unique. It may not even turn out to be particularly rare. We will know in a week. And not one GOP senator will be able to say he or she wasn’t warned.

https://www.washingtonpost.com/opinions/replacing-obamacare-is-a-make-or-break-moment-for-republicans/2017/06/25/c5f7775a-59c9-11e7-9fc6-c7ef4bc58d13_story.html?utm_term=.602544feab43

Patient Protection and Affordable Care Act

From Wikipedia, the free encyclopedia
Patient Protection and Affordable Care Act
Great Seal of the United States
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. 119 through 124 Stat. 1025(906 pages)
Legislative history
  • Introduced in the House as the “Service Members Home Ownership Tax Act of 2009” (H.R. 3590byCharles Rangel (DNYon September 17, 2009
  • Committee consideration by Ways 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 (60–39with amendment
  • House agreed to Senate amendment on March 21, 2010 (219–212)
  • Signed into law by President Barack Obama on 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 President Barack 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 of people without health insurance, with estimates ranging from 20–24 million additional people 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 governmentsconservative advocacy groupslabor 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][18]

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][18] 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 market were 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 credits.[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 planMedicaidMedicare 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 CBOGruber 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 issued by the Health Resources and Services Administration to implement this provision 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” appropriations Consolidated 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

In 2012 Senator Sheldon Whitehouse created this summary to explain his view on the act.

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-paymentsco-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] These states can be exempt 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 under 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 mitigation of 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 conservative The Heritage 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 Clinton proposed 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 HatchChuck GrassleyBob 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]

President Obama addressing Congress regarding healthcare reform, September 9, 2009

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 BaucusJeff Bingaman and Kent Conrad, along with Republicans Mike EnziChuck 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 ratingand 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 BakerBob DoleTom 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]

Tea Party protesters at the Taxpayer March on Washington, September 12, 2009

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 Financecommittees. 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 Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill; House Speaker Nancy 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]

Jim Clyburn and Nancy Pelosi celebrating after the House passes the amended bill on March 21

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

Affordable Care Act (ObamaCare). County By County Projected Insurer Participation in Health Insurance Exchanges.

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] The uninsured rate dropped in every congressional district in the U.S. between 2013 and 2015.[196] 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] Similarly, the Urban Institute issued a report in in December 2016 that said that about 19.2 million non-elderly Americans had gained health insurance coverage from 2010 to 2015.[197] 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.[198] As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.[199]

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.[200] 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.[201]

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.[202] 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.[203]

Medicaid expansion

Medicaid expansion by state, as of September 1, 2015.[204]

  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.[199] 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.[198] 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.[205] 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.[206] 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.[207]

States that rejected the Medicaid expansion could maintain their Medicaid eligibility thresholds, which in many states were significantly below 133% of the poverty line.[208] Many states did not make Medicaid available to childless adults at any income level.[209] Because subsidies on exchange insurance plans were not available to those below the poverty line, such individuals had no new options.[210][211] 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.[205]

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.[212] The federal government initially paid for 100% of the expansion (through 2016). The subsidy tapered to 90% by 2020 and continued to shrink thereafter.[213] Several states argued that they could not afford their 10% contribution.[213][214] 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,[215]

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.[216] 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.[217]

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.[218]

Healthcare insurance costs

U.S. healthcare cost information, including rate of change, per-capita, and percent of GDP. (Data source: Centers for Medicare and Medicaid Services[219])

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.[220] 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.[221]

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.[201] From 2008-2010 (before passage of the ACA) health insurance premiums rose by an average of 10% per year.[222]

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.[223][224][225][226] A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation.[227] 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.[228]

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.[229]

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 deductibleco-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.[230]

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.[231]

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.[232] 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.[233]

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][234][235] The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:[8][236] 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,[237][238] revenue would exceed spending in those subsequent years.[239] 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”[240]—ultimately extending the solvency of the Medicare trust fund by 8 years.[241]

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.[242][243][244]

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 Advantagepolicies that the Government Accountability Office and Medicare Payment Advisory Commission found to be excessively costly relative to government Medicare;[245][246] and reductions in Medicare reimbursements to hospitals that failed standards of efficiency and care.[245]

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.[240][247] 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”.[248]

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.[249][250][251] 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.[252][253][254]

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.”[255] 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.[256]

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;[257][258] stating, “innovations in the delivery of medical care, like greater use of electronic medical records[259] 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.”[257]

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.[260] 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”.[261][262]

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[263] for employees working over 30 hours per week.[264]

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.”[265] 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.[266]

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.[267] 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.[268][269] 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.[270][271] In the public sector full-time jobs turned into part-time jobs much more than in the private sector.[270][272] A 2016 study found only limited evidence that ACA had increased part-time employment.[273]

Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees,[274][unreliable source?][275][unreliable source?] to reflect the 30-hour-or-more definition for full-time worker.[267] 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).[269] Trends in working hours[276] and the effects of the Great Recessioncorrelate with part-time working hour patterns.[277][278] 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.[269][276][279] Relatively few firms employ over 50 employees[269] and more than 90% of them offered insurance.[280] Workers without employer insurance could purchase insurance on the exchanges.[281]

Most policy analysts (on both right and left) were critical of the employer mandate provision.[268][280] They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful;[282][283] that the raised marginal cost of the 50th worker for businesses could limit companies’ growth;[284] that the costs of reporting and administration were not worth the costs of maintaining employer plans;[282][283] and noted that the employer mandate was not essential to maintain adequate risk pools.[285][286] The effects of the provision generated vocal opposition from business interests and some unions not granted exemptions.[283][287]

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.[288]

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.[289]

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.[290]

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.[291][292] About 29% of whites approve of the law, compared with 61% of Hispanics and 91% of African Americans.[293]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.[294]

Congressional Democrats celebrating the 6th anniversary of the Affordable Care Act in March 2016 on the steps of the U.S. Capitol.

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.[295] 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.[296][297]

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.[298] Other polls found that people were concerned that the law would cost more than projected and would not do enough to control costs.[299]

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.[295] 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”.[300] 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”.[301]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).[302]

A 2014 poll reported that 26% of Americans support ACA.[303] Another held that 8% of respondents say that the Affordable Care Act “is working well the way it is”.[304] In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.[305]

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.[306] 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.[307]

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.[308]

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.[309] Approximately 45% were unsure whether the “repeal of Obamacare” also meant the “repeal of the Affordable Care Act.”[309] 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%).[309]

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.[310]

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][311] 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.[312] 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.[312] Use of the term in a positive sense was suggested by Democrat John Conyers.[313] Obama endorsed the nickname, saying, “I have no problem with people saying Obama cares. I do care.”[314]

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…”.[315]

In October 2013 the Associated Press and NPR began cutting back on use of the term.[316] 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”.[317]

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.[318] “Death panel” referred to two claims about early drafts.

One was that under the law, seniors could be denied care due to their age[319] 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).[320] 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.[321][322]

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.[323] The provision was not included in ACA.[324]

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.[325] A poll in August 2012 found that 39% of Americans believed the claim.[326] The allegation was named PolitiFact‘s “Lie of the Year”,[318][327] one of FactCheck.org‘s “whoppers”[328][329] and the most outrageous term by the American Dialect Society.[330] AARP described such rumors as “rife with gross—and even cruel—distortions”.[331]

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).[332][333][334][335][336]

Illegal immigrants

ACA does not provide benefits to illegal immigrants.[337] It explicitly denies insurance subsidies to “unauthorized (illegal) aliens”.[25][26][338]

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.”[339]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.[340]

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.[341]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.”[342]

Opposition

Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions,[343][344] conservative advocacy groups,[345][346] Republicans, small business organizations and the Tea Party movement.[347]These groups claimed that the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit.[348] Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods.[349][350] President Donald Trump has repeatedly promised to “repeal and replace” it.[351][352]

As of 2013 unions that expressed concerns about ACA included the AFL-CIO,[353] which called ACA “highly disruptive” to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of TeamstersUnited 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.”[344] 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.”[343]

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.[354] Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.[355]

Legal challenges

National Federation of Independent Business v. Sebelius

Opponents challenged ACA’s constitutionality in multiple lawsuits on multiple grounds.[356][357][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.[358]

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.[359][360]

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.[361]

House v. Price

In United States House of Representatives v. Price (previously 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 ACA 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.[362] In 2017, the uncertainty about whether the payments would continue caused Blue Cross Blue Shield of North Carolina to try to raise premiums by 22.9 percent the next year, as opposed to an increase of only 8.8 percent that it would have sought if the payments were assured.[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 111th112th, 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.[283][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 Republicansto repeal parts of the law “without threat of a Democratic filibuster.”[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]

On May 4, 2017, the United States House of Representatives voted to pass the American Health Care Act (and thereby repeal most of the Affordable Care Act) by a narrow margin of 217 to 213, sending the bill to the Senate for deliberation.[395] The Senate has indicated they will write their own version of the bill, instead of voting on the House version.[396]

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”.[397][398] However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,[399] and several million more risked seeing their current plans cancelled.[400][401][402]

Obama’s previous unambiguous assurance that consumers’ could keep their own plans became a focal point for critics, who challenged his truthfulness.[403][404] 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.”[405] Various bills were introduced in Congress to allow people to keep their plans.[406]

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.[407]

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.[407]

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.[408]

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[409]

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,[410] although some later accepted the expansion.[411][412]

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.[413][414]

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%.[415] 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.[280][416][417]

The Community Living Assistance Services and Supports Act (or CLASS Act) was enacted as Title VIII of the ACA. 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.[418] The CLASS Act was repealed January 1, 2013.[419]

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.[420] Operations stabilized in 2014, although not all planned features were complete.[421][422]

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.[423] 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.[424] The proportion of workers with employer-sponsored health insurance requiring a deductible climbed to about three-quarters in 2012 from about half in 2006.[223]
  • ACA changes[223] 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][224]

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 ACA website.[425]

In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.[426] 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.[427]

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.[428][not in citation given]

A 2016 analysis found that health care spending by the middle class was 8.9% of household spending in 2014.[429]

2015

By the beginning of the year, 11.7 million had signed up (ex-Medicaid).[430] On December 31, 2015, about 8.8 million consumers had stayed in the program. Some 84 percent, or about 7.4 million, were subsidized.[431]

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.[432]

The average price of non-generic drugs rose 16.2% in 2015 and 98.2% since 2011.[429]

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.[206] 11.1 million were still covered, a decline of nearly 13 percent.[433] 6.1 million uninsured 19-25 year olds gained coverage.[434]

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.[435]

Insurers

The five major national insurers expected to lose money on ACA policies in 2016.[436] UnitedHealth withdrew from the Georgia and Arkansas exchanges for 2017, citing heavy losses.[203] Humana exited other markets, leaving it operating in 156 counties in 11 states for 2017.[437] 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.[438][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.[439] 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.[440] Aetna and Humana’s exit for 2017 left 8 rural Arizona counties with only Blue Cross/Blue Shield.[441]

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.[442]

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,[443] while only 2 percent of 2016 eligibles had only one choice.[444]

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.[428]

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.[445]

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.[220] 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.[221]

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.[446]

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 sign up 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).[447] 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.[447] 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.”[448] 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.[449]

Aetna CEO Mark Bertolini stated that ACA was in a “death spiral” of escalating premiums and shrinking, skewed enrollment.[450] 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 announced that it would exit the exchange market in all remaining states.[451] It stated that its losses had grown from $100M in 2014 to $450M in 2016.[452] Wellmark withdrew from Iowa in April.[453] As of May, no insurer had indicated its intention to offer ACA insurance in Nebraska.[451] Also in May Blue Cross and Blue Shield of Kansas City announced it would withdraw from Missouri and Kansas’s individual markets in 2018, potentially leaving nearly 19,000 residents in Western Missouri without a coverage option.[454] Anthem announced plans to withdraw from Ohio[455] and later Wisconsin[456] and Indiana,[457] describing the market as “volatile” and referring to the difficulty in pricing its plans “due to the shrinking individual market as well as continual changes in federal operations, rules and guidance.”[455]

The CBO reported in March 2017 that the healthcare exchanges were expected to be stable; i.e., they were not in a “death spiral.”[458] In June, Centene announced that it intended to initiate coverage in Nevada, Kanasa and Missouri and expand coverage in Ohio and Florida.[459]

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 established to help prevent insurers from artificially selecting lower-risk pools.[460]

In May the United States House of Representatives voted to repeal the ACA.[461][462]

See also

https://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act

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The Pronk Pops Show 858, Part 2 — Story 1: House Freedom Caucus Is Right: First Complete Clean Repeal and Then Replace Obamacare — No Three Phases/Prongs Bull — Change Your Rules or American People Will Replace You — Restore Free Market Competition In Health Insurance Sector So That Companies and Consumers Are Free of Government Mandates and Dictates Thereby Lowering Premiums and Deductibles — Freedom Works — Repeal and Replace Obamacare Now! — Videos

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Part 2 — Story 1: House Freedom Caucus Is Right: First Complete Clean Repeal and Then Replace Obamacare — No Three Phases/Prongs Bull — Change Your Rules or American People Will Replace You — Restore Free Market Competition In Health Insurance Sector So That Companies and Consumers Are Free of Government Mandates and Dictates Thereby Lowering Premiums and Deductibles  — Freedom Works — Repeal and Replace Obamacare Now! — Videos

 

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What Is Budget Reconciliation?

Video Transcript:

Led by President Donald Trump, Republicans have promised to repeal the Affordable Care Act. They have control of both houses of Congress and the White House, but they still have one big obstacle in that effort.

In the Senate, opponents could stage a filibuster — the right of the minority to try to talk a bill to death and keep senators from voting. It takes 60 votes to stop a filibuster. Republicans have a majority but only 52 seats. And Democrats say they won’t help take apart the health law they voted to pass seven years ago.

Instead, Republicans are vowing to use a budget procedure called “reconciliation.” It comes from a 1974 law called the Congressional Budget and Impoundment Control Act. Lots of major health laws have been passed using reconciliation, including those guaranteeing the right to emergency room care, creating the Children’s Health Insurance Plan, and allowing private plans as an alternative to traditional Medicare coverage.

Here’s how reconciliation would work. First, Congress has to pass a budget resolution.

That budget document has to be agreed on by the House and Senate, but it doesn’t go to the president for his signature.

The budget resolution does two main things. First, it sets spending targets for federal programs Congress funds every year. Those are known as appropriations.

But there are also programs funded by the federal government that don’t need annual approvals from Congress. These include tax cuts or increases and so-called entitlement programs like Medicare and Medicaid.

So the budget resolution also instructs the congressional committees in charge of those programs to propose changes in the law that would “reconcile” how much those programs cost with the targets set by the budget. This is what Republicans would use to order changes to the Affordable Care Act.

When the committees report back their proposed changes, they are assembled into a budget reconciliation bill.

In the Senate, budget reconciliation has its own special rules that make it easier to pass. Debate is strictly limited, and the bill only needs a simple majority to pass.

But there are limits, too. Budget reconciliation bills can only change things that directly impact the federal budget — either adding to or reducing federal spending.

For the Affordable Care Act, that means Congress could use budget reconciliation to eliminate spending, like the help people get to pay their premiums or funding to states to expand the Medicaid program for the poor. It can also repeal the taxes that help pay for those benefits, including the tax penalties for individuals who fail to have insurance.

But Congress can’t use reconciliation to change parts of the health law like provisions requiring insurance companies to provide certain benefits or sell coverage to people with preexisting conditions. Those don’t directly affect federal spending.

That has led insurance companies to complain that they will go broke if they still have to sell to sick people, but healthy people won’t have any incentive to get covered. In that case, they say, only sick people will buy insurance, and premiums will skyrocket.

And the new Republican Congress seems set on using the technique to take apart the health law. Whether that’s a good idea may depend on whether you favor or oppose the Affordable Care Act.

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Watch House Freedom Caucus members speak out on health care bill

Reps. Gohmert, Meadows detail the new ObamaCare proposal

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FNN: Paul Ryan’s FULL PowerPoint Presentation on American Health Care Act (Obamacare Replacement)

AWESOME!! PRESIDENT TRUMP KEEPING HIS PROMISE ON OBAMACARE REPEAL AND REPLACE

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Reconciliation in Congress

Exclusive — Rand Paul: ‘Easily 35 No Votes’ Against Paul Ryan’s Obamacare 2.0, ‘I Would Predict They Pull Bill, Start Over’

by MATTHEW BOYLE

Sen. Rand Paul (R-KY) told Breitbart News exclusively on Tuesday afternoon that he expects House Speaker Paul Ryan will be forced to pull the American Health Care Act (AHCA) before a scheduled Thursday vote because Ryan will not get the votes to pass the legislation.

The AHCA has been dubbed “Obamacare Lite” by Paul — a leading conservative critic of the plan — and by other conservatives as “RyanCare,” “RINO-Care,” and “Obamacare 2.0,” since the bill does not actually fully repeal Obamacare and keeps many of the main structures that the now-former President Barack Obama installed in the healthcare system. It has come under intense scrutiny from both sides of the Republican Party — moderates and conservatives are lining up against the bill — and Ryan, despite publicly projecting confidence, cannot find the necessary 216 votes to pass the legislation.

Paul, one of the leading senators out of more than a dozen Republicans in the upper chamber criticizing the bill there, told Breitbart News in this exclusive interview he believes there are at least 35 House Republicans ready to vote against the bill in its current form. And he predicted that, unless some major changes come to the legislation between now and the scheduled vote on Thursday, Ryan will need to withdraw the bill and Republicans will have to start from scratch with a new bill and a new strategy on Obamacare.

Paul said in the in-person interview at his U.S. Senate office in the Russell Senate Office Building:

I think there’s easily 35 no votes right now so unless something happens in the next 24 hours, I would predict they pull the bill and start over. I think if conservatives stick together, they will have earned a seat at the table where real negotiation to make this bill an acceptable bill will happen. But it’s interesting what conservatives are doing to change the debate. We went from keeping the Obamacare taxes for a year—hundreds of billions of dollars—but they’re coming towards us because we’re standing firm. So we have to stick together, and if we do stick together there will be a real negotiation on this. The main goal I have is not to pass something that does not fix the situation. If a year from now, insurance rates and premiums are still going through the roof and it’s now a Republican plan it will be a disservice to the president and all of us if we pass something that doesn’t work.

.@RandPaul to @mboyle1: Obamacare Lite will hurt us in the next election. This bill will either get stopped or pulled in the next 48 hrs.

There is plenty of reason to believe that Paul is correct in predicting Ryan does not have the votes to pass this legislation and will need to pull the bill to start over. Despite overtures from President Donald Trump, the House Freedom Caucus members — and particularly its chairman Rep. Mark Meadows (R-NC) — remain steadfastly opposed to the bill.

 NBC News has confirmed at least 26 Republicans who are opposed:

NBC News has now ID’ed 26 House GOPers who are opposed/leaning strongly against House health-care bill, per @AlexNBCNews & @LACaldwellDC

But Breitbart News can confirm several more than that are definitely opposed to the legislation. To kill the bill, Republicans need just 21 Republicans opposed—and some are talking about holding a press conference on Wednesday or Thursday with the necessary number of House Republicans to crush RyanCare, appearing arm-in-arm in public opposition before a vote.

House GOP leadership made some last minute changes, too, which Paul — in his interview with Breitbart News — flatly said “no,” were not enough to get the bill passed. Regarding those changed, Paul said:

If you keep all the insurance mandates, and you keep subsidizing insurance, basically it’s Obamacare Lite. So I think it’s still Obamacare Lite. The modifications, some are going in the right direction, but they actually expanded some of the subsidies. So one of the new things about it is it’s actually $75 billion more in subsidies. So, I think they’re stuck trying to split the baby. They’re trying to give conservatives a few token changes. And they’re trying to give the moderates more subsidies.

Paul added that Ryan would not have dragged President Trump into this awful position if he had been more open and inclusive in the process from the beginning. In effect, Paul argued as he has done before, that Ryan is hurting President Trump by doing this the way he is doing it. Paul said:

I’m still unclear as to why they completely ignored conservatives early on in the process and then they had the audacity to look at conservatives and say ‘this is what you all campaigned on.’ That just, frankly, was never true. I was elected in 2010 in the big Tea Party wave that was for repealing Obamacare root and branch, rip the whole thing out. We were for repealing it. I still think that our grassroots conservative supporters are for repealing it. But somewhere along the line, Paul Ryan decided that it wasn’t so much about repealing it but about replacing it with Obamacare Lite. And I think that was a tactical error on their part to think ‘oh, we’ll just be for this and everybody will be for this’ when in reality no conservatives are really for the Ryan plan.

Paul would not say if Ryan will lose the confidence necessary to run the House of Representatives if this bill fails, as some have suggested. When asked if Ryan can still run the House if the bill goes down, Paul told Breitbart News that instead he thinks the bill going down would lead to real negotiations on healthcare reform. He said:

I think what it will be is the real negotiations will begin the moment his bill fails, and when his bill fails conservatives will have a seat at the table. As long as conservatives stay unified and don’t start negotiating one person at a time — what’s a really bad part of negotiations is if everybody starts saying individually ‘oh if you give me this, give me this, give me this’ because then you won’t really fix the main thrust of the bill and the main outcome is that insurance premiums continue to rise and we continue to bail out insurance companies that’s not repeal of Obamacare—that’s Obamacare Lite.

More from Sen. Rand Paul’s latest exclusive interview with Breitbart News is forthcoming.

http://www.breitbart.com/big-government/2017/03/21/exclusive-rand-paul-easily-35-no-votes-paul-ryans-obamacare-2-0-predict-pull-bill-start/

Conservative Review

Member Name Party State Liberty Score Years in DC Next Election

 Track Gary Palmer

Rep.

Gary Palmer R AL-6 A 100% 2 2018

David Brat

Rep.

Dave Brat R VA-7 A 100% 2 2018

Sen.

Mike Lee R UT A 100% 6 2022

Rep.

Louie Gohmert R TX-1 A 98% 12 2018

Sen.

Ted Cruz R TX A 97% 4 2018

Rep.

Jim Bridenstine R OK-1 A 97% 4 2018

Rep.

Justin Amash R MI-3 A 96% 6 2018

Rep.

Jeff Duncan R SC-3 A 96% 6 2018

Rep.

Jim Jordan R OH-4 A 96% 10 2018

Rep.

Thomas Massie R KY-4 A 94% 4 2018

Benjamin Sasse

Sen.

Benjamin Sasse R NE A 94% 2 2020

Rep.

Mark Meadows R NC-11 A 94% 4 2018

Ken Buck

Rep.

Ken Buck R CO-4 A 94% 2 2018

Rep.

Raul Labrador R ID-1 A 93% 6 2018

Sen.

Rand Paul R KY A 92% 6 2022

Trent Franks

Rep.

Trent Franks R AZ-8 A 90% 14 2018

Rep.

David Schweikert R AZ-6 A 90% 6 2018

Rep.

Mark Sanford R SC-1 A 90% 3 2018

Sen.

Tim Scott R SC B 89% 4 2022

Rep.

Ron DeSantis R FL-6 B 87% 4 2018

Rep.

Tom McClintock R CA-4 B 86% 8 2018

Rep.

Scott DesJarlais R TN-4 B 85% 6 2018

Rep.

Trey Gowdy R SC-4 B 85% 6 2018

Rep.

Doug Lamborn R CO-5 B 85% 10 2018

Rep.

Randy Weber R TX-14 B 84% 4 2018

Rep.

Paul Gosar R AZ-4 B 84% 6 2018

Rep.

Mo Brooks R AL-5 B 84% 6 2018

Rep.

Kenny Marchant R TX-24 B 84% 12 2018

Rep.

Sam Johnson R TX-3 B 82% 25 2018

Rep.

Steve King R IA-4 B 81% 14 2018

John Ratcliffe

Rep.

John Ratcliffe R TX-4 B 81% 2 2018

Jody Hice

Rep.

Jody Hice R GA-10 B 81% 2 2018

Rep.

Dana Rohrabacher R CA-48 B 80% 28 2018

Rep.

Andy Harris R MD-1 B 80% 6 2018

Rep.

Bill Posey R FL-8 B 80% 8 2018

Rep.

John J. Duncan Jr. R TN-2 B 80% 28 2018

– See more at: https://www.conservativereview.com/scorecard#sthash.RyaYlHY1.dpuf

Freedom Caucus

From Wikipedia, the free encyclopedia
This article is about the U.S. Congressional organization. For the Democratic political action organization, see Democratic Freedom Caucus.
House Freedom Caucus
Chairman Mark Meadows (NC)
Founded January 26, 2015; 2 years ago
Split from Republican Study Committee
Ideology Conservatism
Fiscal conservatism
Social conservatism[1]
Political position Right-wing to Far-right[2][3][4][5][6]
National affiliation Republican Party
Seats in the House

29 / 435

The Freedom Caucus, also known as the House Freedom Caucus, is a congressional caucus consisting of conservative Republican members of the United States House of Representatives.[7] It was formed in 2015 by a group of Congressmen as what member Jim Jordan called a “smaller, more cohesive, more agile and more active” group of conservatives.[8]

Many members are also part of the Republican Study Committee, another conservative House group.[8][9] The caucus is sympathetic to the Tea Party movement.[10] According to its mission statement, it “gives a voice to countless Americans who feel that Washington does not represent them. We support open, accountable and limited government, the Constitution and the rule of law, and policies that promote the liberty, safety and prosperity of all Americans.”[11]

History

The origins of the caucus lie at the mid-January 2015 Republican congressional retreat in Hershey, Pennsylvania. Nine conservative active Republican members of the House began planning a new Congressional caucus separate from the Republican Study Committee and apart from the House Republican Conference. The group ultimately became the nine founding members and the first board of directors for the new caucus consisting of Republican Representatives Scott Garrett of New Jersey, Jim Jordan of Ohio, John Fleming of Louisiana, Matt Salmon of Arizona, Justin Amash of Michigan, Raúl Labrador of Idaho, Mick Mulvaney of South Carolina, Ron DeSantis of Florida and Mark Meadows of North Carolina.[12] The group debated over a name for their new caucus eventually settling on “House Freedom Caucus” (HFC) because, according to founding member Mick Mulvaney, “it was so generic and universally awful that we had no reason to be against it.” The group of nine founding members in Hershey set as a criterion for new members that they had to be willing to vote against Speaker of the United States House of Representatives John Boehner on legislation that the group opposed.[13]

During the crisis over the funding of the Department of Homeland Security in early 2015, the Caucus offered four plans for resolution, but all were rejected by the Republican leadership. One of the caucus leaders, Labrador of Idaho, said the Caucus will offer an alternative that the most conservative Republican members could support.[14][needs update]

The House Freedom Caucus was involved in the resignation of Boehner on September 25, 2015, and the ensuing leadership battle for the new Speaker.[15] Members of the Caucus who had voted against Boehner for Speaker felt unfairly punished, accusing him of cutting them off from positions in the Republican Study Committee and depriving them of key committee assignments.[not in citation given] Boehner found it increasingly difficult to manage House Republicans with the fierce opposition of the Freedom Caucus, and he sparred with House Republican members (who later created and became members of the Freedom Caucus when it was created in 2015) in 2013 over their willingness to shut down the government in order to accomplish goals such as repealing the Affordable Care Act.[13][16][not in citation given]

Initially, Kevin McCarthy, the House Majority Leader, was the lead contender, but the Freedom Caucus withheld its support.[17] However, McCarthy withdrew from the race on September 28, 2015.[18] On the same day as McCarthy’s withdrawal, Reid Ribble resigned from the Freedom Caucus saying he had joined to promote certain policies and could not support the role that it was playing in the leadership race.[19]

On October 20, 2015, Paul Ryan announced that his bid for the Speaker of the United States House of Representatives was contingent on an official endorsement by the Freedom Caucus.[20] While the group could not reach the 80% approval that was needed to give an official endorsement, on October 21, 2015, it announced that it had reached a supermajority support for Ryan.[21] On October 29, 2015, Ryan succeeded John Boehner as the Speaker of the House.[22]

On November 17, 2015, Jim Jordan was re-elected as Chairman of the caucus.[citation needed]

The group has faced backlash from the Republican Party establishment during the 2016 election cycle.[23] One of its members, Congressman Tim Huelskamp, a Tea Party Republican representing Kansas’s First District, was defeated during a primary election on August 2, 2016, by Roger Marshall.[24] GOP Establishment PACs, many of whom also opposed Donald Trump, spent nearly $2 million to defeat Huelskamp.[25]

Membership

Congressional District map for Freedom Caucus membership of the 114th Congress. Former members in light color.

Members of the House Freedom Caucus as of March 2017 include:

Former members

See also

https://en.wikipedia.org/wiki/Freedom_Caucus

It’s Rand Paul vs Paul Ryan in the battle over Obamacare — and the future of the GOP

Brandon Morse

It’s Rand Paul vs Paul Ryan in the battle over Obamacare — and the future of the GOP

A protester wears a Repeal Obamacare button on his jacket during a Freedom Works rally Wednesday against the proposed GOP health care plan across from the U.S. Capitol in Washington, D.C. (Justin Sullivan/Getty Images)

The in-house Republican battle over the repeal of Obamacare is about to boil over as Kentucky Sen. Rand Paul and Speaker of the House Paul Ryan (R-Wis.) are engaged in an increasingly sharp war over words over their disagreements on how to proceed forward with the promised repeal and replace of former President Obama’s signature legislation.

Paul has been waging a war against the House GOP Obamacare repeal and replace plan since before it was given to the public. Calling it “Obamacare Lite,” Paul has lambasted not only the bill, but his fellow Republicans for their less-than-diligent attempts at getting rid of the unpopular health care law. This time, he turned his attention toward Ryan, who has been the bill’s primary spokesman.

“I think that Paul Ryan’s selling [Donald Trump] a bill of goods that he didn’t explain to the president, and the grassroots doesn’t want what Paul Ryan is selling,” Paul told CNN.

Paul Ryan, during an segment on CNN’s “The Lead with Jake Tapper,” fired back at the Kentucky senator, claiming that his remarks were a jab at President Donald Trump.

“Frankly, I think that’s kind of an insulting remark to the president — as if he doesn’t know what he’s doing,” Ryan said.

“We think this is a smarter way to go,” Ryan said to Tapper. “The alternative is the status quo, and the status quo is in the middle of a collapse.”

Ryan has made the case that this version of the Obamacare repeal bill is the “closest we will ever get” to repealing it.

Paul, however, believes that Trump is open to changing his mind on the health care bill, despite his prior statements of broad approval, and that it’s Republican leadership who have “dug in their heels.”

“They are not going to compromise. So the only way that we are going to get to a compromise where they listen to the grassroots that wants complete repeal, the only way we got to that compromise is that we have to demonstrate to the House leadership that we have the votes to stop them.”

Other Republicans in Congress have joined Paul in his efforts to push a more conservative version of a repeal bill, which focuses solely on repeal, and repeal alone. Rep. Jim Jordan and Paul have both submitted versions of the bill in the Senate and the House, and has the support of conservative legislators such as Rep. Justin Amash, Sen. Mike LeeRep. Jeff Duncan, and Sen. Tom Cotton. This list of allies now also includes a group of moderate Republicans rattled by the recent Congressional Budget Office report.

As the battle continues between the conservatives and GOP leadership, the faith of the voters hangs in the balance, according to the conservatives. Paul believes that should the GOP pass “Obamacare Lite,” Republicans will pay for it come election time. Duncan wrote in the Daily Signal that should the bill pass, voters “will feel betrayed.”

If that is true, then winner of the struggle between Paul and Ryan may determine the GOP’s future momentum.

http://www.theblaze.com/news/2017/03/17/its-rand-paul-vs-paul-ryan-in-the-battle-over-obamacare-and-the-future-of-the-gop/

Rand Paul Unveils His Brilliant Obamacare Replacement Plan

WASHINGTON (AP) — Time for talk running out, President Donald Trump on Tuesday warned wavering House Republicans that their jobs were on the line in next year’s elections if they failed to back a GOP bill that would overhaul Barack Obama’s Affordable Care Act.

The countdown quickened toward an expected vote Thursday on legislation undoing much of the law that provided health coverage to some 20 million Americans. Trump huddled behind closed doors with rank-and-file Republicans just hours after GOP leaders unveiled changes intended to pick up votes by doling out concessions to centrists and hardliners alike.

“If we fail to get it done, fail to (meet) the promises made by all of us, including the president, then it could have a very detrimental effect to Republicans in ’18 who are running for re-election,” said Rep. Mike Conaway, R-Texas. “If it fails, then there will be a lot of people looking for work in 2018.”

Trump’s message to Republicans: “If you don’t pass the bill there could be political costs,” said Rep. Walter Jones, R-N.C.

The outlook for House passage remains dicey even with the revisions.

The GOP bill would scale back the role of government in the private health insurance market, and limit future federal financing for Medicaid. It would also repeal tax cuts on the wealthy that Democrats used to pay for Obama’s coverage expansion. Fines enforcing the Obama-era requirement that virtually all Americans have coverage would be eliminated.

The nonpartisan Congressional Budget Office estimates that 24 million fewer people will have health insurance in 2026 under the GOP bill.

Trump warned House Republicans they’d seal their political doom if they waver, with the party potentially losing majority control of the House. Still, several conservatives were steadfast in their opposition even after the session with Trump and the leadership’s changes.

“The president wouldn’t have been here this morning if they have the votes,” said Rep. Rod Blum, R-Iowa, a member of the Freedom Caucus who complained that the GOP bill leaves too much government regulation in place.

Rep. Don Bacon, R-Neb., said he was convinced to back the bill in part by Trump’s urging and the changes.

“I think a vote ‘no’ is a vote for Obamacare,” Bacon said. “We can vote for this, and continue to make it better. I intend to vote ‘yes’ Thursday.”

Speaker Paul Ryan, R-Wis., told reporters that if Republicans pass the legislation, “people will reward us. If we don’t keep our promise, it will be very hard to manage this.”

If the bill advances, prospects are uncertain in the Senate, where Republicans hold a slim majority. Six GOP senators have expressed deep misgivings including Tom Cotton of Arkansas, who said Tuesday he cannot support the House bill.

In an Associated Press interview, Senate Majority Leader Mitch McConnell, R-Ky., signaled he’d use Trump’s clout to pressure unhappy Republicans in his chamber. McConnell said he’s optimistic that in the end no Republican senator will want to be held responsible for “Obamacare’s” survival.

“I would hate to be a Republican whose vote prevented us from keeping the commitment we’ve made to the American people for almost 10 years now,” McConnell said.

The House GOP bill would dismantle Obama’s requirements that most people buy policies and that larger companies cover workers. Federal subsidies based on peoples’ incomes and the cost of insurance would end, and a Medicaid expansion to 11 million more low-income people would disappear.

Instead, the bill would provide tax credits based chiefly on age to help people pay premiums. Open-ended federal payments to help states cover Medicaid costs would be cut. Insurers could charge older consumers five times the premiums they charge younger people instead of Obama’s 3-1 limit, and would boost premiums 30 percent for those who let coverage lapse.

The latest changes to the bill by GOP leaders were largely aimed at addressing dissent that the measure would leave many older people with higher costs.

Included was an unusual approach: language paving the way for the Senate, if it chooses, to make the bill’s tax credit more generous for people age 50-64. Republicans said the plan sets aside $85 billion over 10 years for that purpose. The income tax threshold for deducting medical expenses would be lowered to 5.8 percent, from the current 10 percent.

The leaders’ proposals would accelerate the repeal of tax increases Obama imposed on higher earners, the medical industry and others.

On Medicaid, the changes would provide higher federal payments to help states care for older and disabled beneficiaries. States would be able to impose work requirements for able-bodied adults. But the bill would still limit future federal financing for Medicaid, seen by many state officials as a cost shift. Obama’s Medicaid expansion would be repealed.

In a bid to cement support from upstate New Yorkers, the revisions would also stop that state from passing on over $2 billion a year in Medicaid costs to upstate counties, though it exempts Democratic-run New York City from that protection. Local officials have complained the practice overburdens their budgets.

Democrats remain solidly opposed to the GOP repeal effort.

Rep. Chris Collins, R-N.Y., said Trump told Republicans he would campaign for them if they backed the bill.

Associated Press reporters Matthew Daly, Kevin Freking, Richard Lardner, Stephen Ohlemacher in Washington and Thomas Beaumont in Iowa contributed to this report.

http://hosted.ap.org/dynamic/stories/U/US_CONGRESS_HEALTH_OVERHAUL?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2017-03-21-03-20-21

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The Pronk Pops Show 264, May 21,2014, Story 1: Single Payer Government Monopoly on Health Care = Socialized Medicine = A VA Hospital Preview of Death Panels — Delay, Deny, and Lie — The Unacceptable Obama Administration! — Vote The Political Elitist Establishment (PEEs) Out of Office for Incompetence — Part 2 — Videos

Posted on May 22, 2014. Filed under: American History, Blogroll, Budgetary Policy, Business, Communications, Disasters, Drugs, Economics, Employment, Fiscal Policy, Government Spending, Health Care Insurance, History, Illegal Immigration, Immigration, Media, Medicine, Networking, Philosophy, Photos, Politics, Polls, PTSD, Public Sector Unions, Radio, Regulation, Scandals, Science, Security, Social Science, Taxes, Technology, Terror, Unions, United States Constitution, Videos, Violence, War, Wealth, Wisdom | Tags: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |

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The Pronk Pops Show Podcasts

Pronk Pops Show 264: May 21, 2014

Pronk Pops Show 263: May 20, 2014

Pronk Pops Show 262: May 16, 2014

Pronk Pops Show 261: May 15, 2014

Pronk Pops Show 260: May 14, 2014

Pronk Pops Show 259: May 13, 2014

Pronk Pops Show 258: May 9, 2014

Pronk Pops Show 257: May 8, 2014

Pronk Pops Show 256: May 5, 2014

Pronk Pops Show 255: May 2, 2014

Pronk Pops Show 254: May 1, 2014

Pronk Pops Show 253: April 30, 2014

Pronk Pops Show 252: April 29, 2014

Pronk Pops Show 251: April 28, 2014

Pronk Pops Show 250: April 25, 2014

Pronk Pops Show 249: April 24, 2014

Pronk Pops Show 248: April 22, 2014

Pronk Pops Show 247: April 21, 2014

Pronk Pops Show 246: April 17, 2014

Pronk Pops Show 245: April 16, 2014

Pronk Pops Show 244: April 15, 2014

Pronk Pops Show 243: April 14, 2014

Pronk Pops Show 242: April 11, 2014

Pronk Pops Show 241: April 10, 2014

Pronk Pops Show 240: April 9, 2014

Pronk Pops Show 239: April 8, 2014

Pronk Pops Show 238: April 7, 2014

Pronk Pops Show 237: April 4, 2014

Pronk Pops Show 236: April 3, 2014

Pronk Pops Show 235: March 31, 2014

Pronk Pops Show 234: March 28, 2014

Pronk Pops Show 233: March 27, 2014

Pronk Pops Show 232: March 26, 2014

Pronk Pops Show 231: March 25, 2014

Pronk Pops Show 230: March 24, 2014

Pronk Pops Show 229: March 21, 2014

Pronk Pops Show 228: March 20, 2014

Pronk Pops Show 227: March 19, 2014

Pronk Pops Show 226: March 18, 2014

Pronk Pops Show 225: March 17, 2014

Pronk Pops Show 224: March 7, 2014

Pronk Pops Show 223: March 6, 2014

Pronk Pops Show 222: March 3, 2014

Pronk Pops Show 221: February 28, 2014

Pronk Pops Show 220: February 27, 2014

Pronk Pops Show 219: February 26, 2014

Pronk Pops Show 218: February 25, 2014

Pronk Pops Show 217: February 24, 2014

Pronk Pops Show 216: February 21, 2014

Pronk Pops Show 215: February 20, 2014

Pronk Pops Show 214: February 19, 2014

Pronk Pops Show 213: February 18, 2014

Pronk Pops Show 212: February 17, 2014

Pronk Pops Show 211: February 14, 2014

Pronk Pops Show 210: February 13, 2014

Pronk Pops Show 209: February 12, 2014

Pronk Pops Show 208: February 11, 2014

Pronk Pops Show 207: February 10, 2014

Pronk Pops Show 206: February 7, 2014

Pronk Pops Show 205: February 5, 2014

Story 1:  Single Payer Government Monopoly on Health Care = Socialized Medicine = A VA Hospital Preview of Death Panels — Delay, Deny, and Lie — The Unacceptable Obama Administration! — Vote The Political Elitist Establishment (PEEs) Out of Office for Incompetence — Part 2 — Videos

Locations

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Facilities by State

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how_congress_spends_your_money

Obama Finally Addresses V.A. Scandal – The Five

Rep Bachmann (R-MN On Pres Obama’s Handling Of The Veterans Affairs Scandal – Cavuto

Milton Friedman on Libertarianism (Part 4 of 4)

Milton Friedman – Socialized Medicine

Milton Friedman – Health Care in a Free Market

Obama on single payer health insurance

Obama’s Single Payer Health Care System : New World Order

 

What a Single Payer Health Insurance Plan Looks Like

Pres. Obama Veterans Health Care Budget Reform Act

Judge Jeanine Pirro Opening Statement – Veterans Left To Die By The VA – VA Full Blown Scandal

Judge Jeanine Pirro – Veteran Affairs Scandal – V.A. Chief Grilled Over Treatment Of Vets

President facing increased scrutiny over VA scandal

Chuck Todd: VA Scandal More Dangerous for Obama than ‘Partisanized’ Benghazi

RPT: Obama Admin Warned of VA Problems in ’08 and Did Nothing

Senate gets serious on veteran care wait time

Breaking Top VA Offical Resigns – Another Scandal

VA official resigns amid scandal

CBS’ Major Garrett: Obama Has Been Silent On VA Scandal For Three Weeks

‘You Want to Cut Obama’s Throat!’ Geraldo, Bolling Clash over VA Scandal

ABC: “Outrage Growing” Over Obama Administration’s Handling Of VA Scandal

Gohmert on Phoenix VA Hospital Scandal

VA Probe Exposes Scandal at Multiple Locations

President Obama describing how to reach single payer flashback

obama master plan on health careover the years in his own words–SINGLE PAYER!!!

President Obama Wants A Single Payer Health Care System

[Daily News] Americas military suicide rate explained

U.S. Veterans Face Staggering Epidemic of Unemployment, Trauma & Suicide

The Invisible Wounds of War: Number of Soldiers Committing Suicide Reaches Record High

Jon Stewart Slams President Obama Over VA Scandal

 

VeteransHealthAdmin

 

Whistleblower expands VA wait-list fraud to eighth facility

BY ED MORRISSEY

Add yet another VA facility to the deadly wait-list fraud scandal. The Daily Beast heard from a whistleblower in the Albuquerque VA organization that the same kind of wait-list fraud alleged at seven other facilities occurs in New Mexico as well. Veterans have to wait months to get medical attention, and any investigation may already be too late for some of them:

Add Albuquerque, New Mexico’s to the growing list of VA hospitals accused of keeping secret waiting lists to hide delays for veterans seeking medical care. And it may already be too late to get to the truth and find out what harm, if any, was done to veterans there—VA officials are already destroying records to cover their tracks, a whistleblower inside the hospital tells The Daily Beast. …

“The ‘secret wait list’ for patient appointments is being either moved or was destroyed after what happened in Phoenix,” according to a doctor who works at the Albuquerque VA hospital and spoke exclusively with The Daily Beast. “Right now,” the doctor said, “there is an eight-month waiting list for patients to get ultrasounds of their hearts. Some patients have died before they got their studies. It is unknown why they died, some for cardiac reasons, some for other reasons.”

There’s no proof yet that veterans died while waiting for treatment, like what allegedly happened in Phoenix. But the doctor says it’s quite possible that some veterans would still be alive if they hadn’t been pushed through a record-keeping trap door that buried their requests for medical care.

On March 19, 2014, for example, a patient with a deteriorating heart condition requested to see a doctor. The patient was finally seen only days ago, on May 16, when they were admitted to the hospital for decompensated heart failure. “A near miss” as the VA doctor familiar with the case described it. “He could have died before being seen.”

That patient was fortunate. It remains to be seen whether all of the patients affected by the alleged wait-list fraud in Albuquerque were as fortunate. They certainly weren’t in Phoenix.Stars and Stripes notes that treatment delays have been listed as factors in more than 100 deaths, although over a time frame that begins in 2001:

As controversy swirls around the Veterans Administration over deaths caused by delayed care, an investigation by the Dayton Daily News found that the VA settled many cases that appear to be related to delays in treatment.

A database of paid claims by the VA since 2001 includes 167 in which the words “delay in treatment” is used in the description. The VA paid out a total of $36.4 million to settle those claims, either voluntarily or as part of a court action.

The VA has admitted that 23 people have died because of delayed care, and is facing accusations that hospital administrators are gaming the system to conceal wait times, including using a “secret list” at the VA in Phoenix. …

The Dayton VA in 2009 paid out $140,000 for a 2006 claim that was described as “Failure/Delay in Admission to Hospital or Institution; Medication Administered via Wrong Route; Failure to Order Appropriate Test.”

A pending $3.5 million claim from March 2013 was filed by a man who says delayed treatment of his wife’s cervical cancer resulted in her death in March 2012. The names of the veteran and her widower were redacted.

Issues with access and treatment delays have been around for decades at the VA. That’s the reason why VA Secretary Eric Shinseki imposed the 14-day wait list metric in 2009, when he took over the Department of Veteran Affairs. The move was supposed to correct the chronic problem of timely access for many veterans. Instead, VA facilities across the country appear to have engaged in widespread and suspiciously similar fraud, and no one at the VA from Shinseki on down seems to have bothered to do anything about it — and have lied about knowledge of the issue to boot.

That’s enough for Dana Milbank, who called this weekend for Shinseki to be canned:

Eric Shinseki has served his country honorably as a twice-wounded officer in Vietnam, as Army chief of staff and finally as President Obama’s secretary of veterans affairs.

But his maddeningly passive response to the scandal roiling his agency suggests that the best way Shinseki can serve now is to step aside.

Reports have documented the deaths of about 40 veterans in Phoenix who were waiting for VA appointments — the latest evidence of widespread bookkeeping tricks used at the agency to make it appear as though veterans were not waiting as long for care as they really were. The abuses have been documented over several years by whistleblowers and leaked memorandums, and confirmed by a host of government investigators.

That’s bad enough. Worse was Shinseki’s response when he finally appeared before a congressional committee Thursday to answer questions about the scandal. He refused to acknowledge any systemic problem and declined to commit to do much of anything, insisting on waiting for the results of yet another investigation.

Shinseki did not cover himself in glory in Senate testimony last week. One indication of how big the problem has become was the abrupt dismissal of Robert Petzel, who was already on his way out for retirement in September. However, his replacement turns out to be even more problematic:

The person nominated two weeks ago to replace the VA’s outgoing undersecretary for health was responsible for supervising one of the hospitals at the center of the current scandal.

Dr. Jeffrey Murawsky was nominated on May 1 to replace Dr. Robert Petzel as undersecretary of health at the Department of Veterans of Affairs.   Petzel’s “resignation” was officially announced today, although his impending retirement was first announced last September.

Murawsky is currently the network director–effectively the CEO–of the VA region that includes the Edward Hines, Jr. VA Hospital in Chicago.  Before he moved up the VA hierarchy, he worked as a manager at the hospital.

Hines Hospital was the seventh facility to face allegations of wait-list fraud. Murawsky seems better suited to be the target of the investigation rather than the man running it. It’s time to clean house entirely at the VA.

http://hotair.com/archives/2014/05/19/whistleblower-expands-va-wait-list-fraud-to-eighth-facility/

He KNEW! Obama told of Veterans Affairs health care debacle as far back as 2008

By Jim McElhatton

The Washington Times

The Obama administration received clear notice more than five years ago that VA medical facilities were reporting inaccurate waiting times and experiencing scheduling failures that threatened to deny veterans timely health care — problems that have turned into a growing scandal.

Veterans Affairs officials warned the Obama-Biden transition team in the weeks after the 2008 presidential election that the department shouldn’t trust the wait times that its facilities were reporting.

 


“This is not only a data integrity issue in which [Veterans Health Administration] reports unreliable performance data; it affects quality of care by delaying — and potentially denying — deserving veterans timely care,” the officials wrote.

The briefing materials, obtained by The Washington Times through the Freedom of Information Act, make clear that the problems existed well before Mr. Obama took office, dating back at least to the Bush administration. But the materials raise questions about what actions the department took since 2009 to remedy the problems.

In recent months, reports have surfaced about secret wait lists at facilities across the country and, in the case of a Phoenix VA facility, accusations that officials cooked the books to try to hide long wait times. Some families said veterans died while on a secret wait list at the Phoenix facility.

Last week, Dr. Robert Petzel, undersecretary for health in the Department of Veterans Affairs, resigned. His boss, Secretary Eric K. Shinseki, told Congress he will stay despite growing calls for his resignation.

Mr. Shinseki, a disabled veteran, has headed the department since the beginning of Mr. Obama’s first term, when the VA report identified many of the problems.

“Should they have known? Absolutely, they should have known,” said Deirdre Parke Holleman, executive director of the Washington office for the Retired Enlisted Association, a veterans group, which has not taken a position on whether Mr. Shinseki should resign. “These are problems that should have been dealt with.”


PHOTOS: Eye-popping excuses in American political scandals


In particular, the 2008 transition report referred to a VA inspector general recommendation to test the accuracy of reported waiting times.

Such tests, the report noted, could prompt action if results reveal “questionable differences” between the dates shown in medical records and dates in the Veterans Health Administration’s scheduling system. It’s unclear whether that recommendation was adopted because VA officials have not responded to request for comment.

In Phoenix, officials are looking into whether as many as 40 veterans died while waiting for treatment, with “secret wait lists” used to conceal the delays. Speaking in the Republicans’ weekly address over the weekend, Sen. John McCain, Arizona Republican, said the scandal began in his home state but it has since “gone nationwide.”

“Altogether, similar reports of lengthy waiting lists and other issues have surfaced in at least 10 states,” he said.

Acting VA Inspector General Richard J. Griffin told Congress last week that his office has opened multiple investigations into “reports of manipulated waiting times” in Phoenix as at other facilities.

He said his investigation also aims to find out whether officials in Phoenix purposely left off the names of veterans waiting for care on electronic waiting lists and, if so, whether any veterans died because of the delays in care.

Problems with electronic waiting lists also merited mention in the presidential briefing report.

Audits of outpatient scheduling and patient waiting times completed since 2005 have identified noncompliance with the policies and procedures for scheduling, inaccurate reporting of patient waiting times and errors in [electronic waiting lists],” the briefing papers state.

Briefing reports typically are prepared by career federal employees before a change in power, giving incoming administrations detailed looks at agency operations. The VA report notes that little was done to address the problems surrounding scheduling and wait time accuracy during the George W. Bush administration.

“Although VHA has recognized the need to improve scheduling practices and the accuracy of wait times data, no meaningful action has been taken to achieve this goal today,” officials wrote.

In fact, officials added, nine recommendations arising from inspector general audits from 2005 to 2007 were not implemented by 2008 when officials prepared the report for the incoming administration.

Jim Nicholson, who served as VA secretary during the latter half of the Bush administration, could not be reached for comment.

The briefing materials do not reveal any concerns about outright fraud in manipulating waiting times, but they make repeated references in summarizing past audits and reviews about data accuracy.

“This report and prior reports indicate that the problems and causes associated with scheduling, waiting times and wait lists are systemic throughout the VHA,” officials told the incoming administration.

Testifying to Congress last week, Mr. Shinseki said most veterans are satisfied with their health care, “but we must do more to improve the timely access to that care.”

The American Legion has called on Mr. Shinseki and Allison Hickey, VA undersecretary for benefits, to resign.

“They are both part of VA’s leadership problem,” American Legion Commander Daniel Dellinger said in a statement Friday. “This isn’t personal. VA needs a fundamental shift in leadership if it is to defeat its systematic lack of accountability.”


http://www.washingtontimes.com/news/2014/may/18/obama-warned-about-va-wait-time-problems-during-20/

Exclusive: VA Scandal Hits New Hospital

Veterans with serious heart conditions, gangrene, and even brain tumors waited months for care at the Albuquerque VA hospital, a whistleblowing doctor tells The Daily Beast.

Add Albuquerque, New Mexico’s to the growing list of VA hospitals accused of keeping secret waiting lists to hide delays for veterans seeking medical care. And it may already be too late to get to the truth and find out what harm, if any, was done to veterans there—VA officials are already destroying records to cover their tracks, a whistleblower inside the hospital tells The Daily Beast.

Last month, word broke that the Department of Veterans Affairs hospital in Phoenix kept a secret waiting list that allegedly led to dozens of preventable deaths. The VA’s inspector general was brought in to investigate the charges and hasn’t yet found any deaths in Phoenix linked to wait times, but his investigation is ongoing. Since then five other facilities have come under fire, leading to calls for VA Secretary Eric Shinseki to step down. And now there’s Albuquerque’s. The evidence for this new secret list may be hard to track down, however.

“The ‘secret wait list’ for patient appointments is being either moved or was destroyed after what happened in Phoenix,” according to a doctor who works at the Albuquerque VA hospital and spoke exclusively with The Daily Beast. “Right now,” the doctor said, “there is an eight-month waiting list for patients to get ultrasounds of their hearts. Some patients have died before they got their studies. It is unknown why they died, some for cardiac reasons, some for other reasons.”

There’s no proof yet that veterans died while waiting for treatment, like what allegedly happened in Phoenix. But the doctor says it’s quite possible that some veterans would still be alive if they hadn’t been pushed through a record-keeping trap door that buried their requests for medical care.

On March 19, 2014, for example, a patient with a deteriorating heart condition requested to see a doctor. The patient was finally seen only days ago, on May 16, when they were admitted to the hospital for decompensated heart failure. “A near miss” as the VA doctor familiar with the case described it. “He could have died before being seen.”

The Albuquerque VA did not respond to requests for comment but Ozzie Garza, director of the VA Regional Office of Public Affairs, provided this statement to The Daily Beast: “We are not familiar with the allegations but will call immediately for an external review as we take all allegations seriously.”

“When everyone found out the IG was doing the audit, the word I heard was ‘Make sure nothing is left out in the open,’” the VA doctor said. “And that ranged from make sure there’s no food out to make sure there’s no information out in the open.” The doctor is not involved in the scheduling process and was unsure of how exactly VA officials would purge the secret wait lists but has heard it discussed among colleagues.

As VA officials reacted nervously to news of an impending audit, the doctor described hearing officials involved in scheduling patient appointments say, “The database had been removed or renamed.” To cover their tracks the doctor said they decided, “Instead of calling it a wait it would be called something like a precedence list.”

On March 19, a patient with a deteriorating heart condition requested to see a doctor. The patient was finally seen on May 16, when they were admitted to the hospital for decompensated heart failure.

When another of the doctor’s colleagues, a physician in a managerial position at the Albuquerque VA, saw the initial story about secret wait lists break he heard him say, “I always knew that Phoenix was better than us at playing the numbers game.”

Secret waiting lists may not be the only problems at the Albuquerque VA, in fact they may only be an accounting trick to mask the deeper issues.

Veterans with heart problems are waiting an average of four months to see a cardiologist at the Albuquerque VA, according to the doctor there who has access to patient records.

There are eight physicians in the cardiology department. But at any given time, only three are working in the clinic, where they see fewer than two patients per day, so on average there are only 36 veterans seen per week. That means the entire eight-person department sees as many patients in a week as a single private practice cardiologist sees in two days, according to the doctor.

For perspective, 60% of cardiologists reported seeing between 50 and 124 patients per week, according to a 2013 survey of medical professionals’ compensation conducted by Medscape. On the low end, the average single private practice cardiologist who participated in the study saw more patients in a week than the Albuquerque VA’s entire eight-person cardiology department.

In some cases, a long wait to see a doctor is just another routine inconvenience of the sort people expect in a large bureaucracy, but other times it can be a matter of life and death.

One veteran’s heart troubles were serious enough that a physician requested they be seen in the next available slot on January 8, 2014. Over three months later, the patient was seen in late April.

A patient whose initial blood test on December 8, 2013 suggested he might have a brain tumor waited until April 28 2014 before he was seen again. Another veteran, diagnosed with gangrene, was referred for surgery so doctors could try to salvage his limb or amputate it if necessary—it’s 36 days after he was initially supposed to see the surgeons and he’s still waiting now.

A second source inside the Albuquerque VA, a medical technician, said the facility provided high quality care. But the technician acknowledged it could take a long time before veterans get in the door to receive it.

The list of patients waiting for tests grew so long in one department that the technician became disheartened and stopped checking it around Christmas of last year. “I honestly stopped doing that because it just overwhelmed me personally,” the technician said.

The VA’s Office of Inspector General began investigating the Albuquerque medical center last year, according The Albuquerque Journal, after employees there reported that appointments were being manipulated to conceal patients’ actual wait times. That would mean that the inspector general, and the VA itself, knew about allegations of corruption there long before the Phoenix story broke in April.

Rep. Jeff Miller, chairman of the House Committee on Veterans’ Affairs, has been beating the drum about wait times and advocating reform since before the latest crisis  put the VA back in the spotlight. “VA’s delays in care problem is real and has already been linked to the recent deaths of at least 23 veterans,” Miller told The Daily Beast.

Yet it wasn’t until the latest VA scandal broke nationally—months after the inspector general first investigated claims that are strikingly similar to what was later reported in Phoenix—that Albuquerque’s came back into focus. The status of the initial investigation still hasn’t been made public.

Last week, New Mexico Senator Tom Udall requested a new investigation into his state’s VA hospitals. Udall called for the audit after his office received dozens of complaints from veterans about long wait times at the VA, and reports that Albuquerque’s schedulers were forging appointment records.

New Mexico is now the seventh state where allegations have emerged about VA medical facilities cooking the books. As new incidents continue to display the same features uncovered in past cases, the details are revealing a common language of bureaucratic corruption communicated across state lines between different VA facilities.

Yet, even as evidence builds of a systemic problem within the VA, the department itself has been slow to acknowledge it and even slower to act. In his testimony before the Senate last week, VA Secretary Shinseki referred to the six cases that had been revealed up to that point as “isolated incidents.”

Veterans, for their part, are divided over the proper response; many believe that the actual care provided by the VA is good and the problem is primarily about access. But as each new week brings another case that seems to show the same pattern of duplicity inside the VA, some are growing impatient.

“Our members are outraged and are demanding true accountability and systemic reform for what appears to be increasingly widespread problems,” said Derek Bennett, chief of staff for Iraq and Afghanistan Veterans of America (IAVA). “We cannot fix the problems until all the facts are on the table,” Bennett said but added that, “scapegoating and politicization of this issue will not reform the Department of Veterans Affairs nor best serve our veterans.”

To encourage getting the facts on the table, the IAVA has started its own initiative to gather stories from veterans and VA employees. “We have partnered with the Project on Government Oversight on vaoversight.org to provide a safe place for whistleblowers to come forward for this very reason,” Bennett said.

Despite the volume of incidents that have already been publicly revealed and theinspector general’s admission last week that he had more evidence pointing to new mismanagement, the VA has not announced any broad reforms or disciplinary actions. In the only major leadership shakeup since the VA became embroiled in the secret wait list charges, Secretary Shinseki announced the resignation last week of Dr. Robert Petzel, his undersecretary for health. But as many were quick to point out, and in what the IAVA called a “cynicial twist,” Petzel was already scheduled to retire this year after a 40-year career.

For Rep. Miller, the time is overdue for change within the VA. “We simply can’t afford to wait for the results of another IG investigation or VA’s internal review when veterans may be at risk,” Miller said. Immediate actions can be taken now, Miller added, even before formal investigations draw their conclusions. “Sec. Shinseki needs to take emergency steps,” he said, “to ensure veterans who may have fallen victim to these schemes get the medical treatment they need.”

On Sunday, the White House, which has remained relatively quiet on the VA’s latest troubles, weighed in with an interview by President Obama’s chief of staff, Denis McDonough.

“The president is madder than hell, and I’ve got the scars to prove it, given the briefings that I’ve given the president,” McDonough told CBS’ Face the Nation. “Madder than hell” was the first echo of Secretary Shinseki, amplifying a phrase he used in his testimony last week to describe his own feelings. The second echo of Shinseki came when McDonough said the president had sent staff to look into the VA investigation and “find out if this is a series of isolated cases or whether this is a systemic issue.”

The VA’s own investigation is ongoing and will continue to attract attention as more revelations, like the claims about the Albuquerque VA, keep coming out. It remains to be seen how leaders who are “madder than hell” will react to the evidence they find and what, if anything, they will order done about the situation.

http://www.thedailybeast.com/articles/2014/05/18/exclusive-v-a-scandal-hits-new-hospital.html

Vets Using Phoenix VA are Angry, Sick and Scared

by Jennifer Hlad

The veterans who use the Phoenix Veterans Affairs Health System are angry, sick and scared.

They say they call and call, but get no answer.

They say they are ignored, disrespected and turned away by employees with no medical training.

They say they wait months for an appointment with a primary care doctor, then wait several more months to see a specialist.

More than 200 veterans and family members packed into American Legion Post 41 to share horror stories of delays, misdiagnoses and poor treatment with the national commander of the American Legion and the interim director of the Phoenix VA. Steve Young took over after whistleblowers revealed secret waiting lists used to cover up backlogs and extensive wait times. One of the whistleblowers, Dr. Samuel Foote, said there are at least 13,000 patients without primary care doctors, and even more who can’t get timely specialty appointments or follow-ups.

He said 40 veterans died while waiting for appointments in Phoenix VA clinics, and VA wrongdoings have surfaced in at least 10 states.

The Legion’s Daniel Dellinger told the crowd that the VA has “a pattern of unresponsiveness that has infected the entire system.”

People in the room waited their turn, then spoke of broken promises, fear and frustration. Some choked back tears; others spoke harshly of misplaced loyalty, angered that they had proudly served in the military yet weren’t being served by the VA in return.

Turned away

Dennis Morris’ arm was swollen, and he wasn’t feeling well, so he and his wife, Lynn, went to the Phoenix VA’s emergency room. They spent the whole night there, she said, and were sent home with a bag of ice.

The next day, his arm was worse — even more swollen and turning black. They went back to the ER and he was released with another bag of ice, she said.

On the third day, she insisted her husband go to the civilian hospital near their home in Sun City. Dennis was diagnosed with cellulitis and two strains of pneumonia, and he spent several days in the hospital. She said she had to write to Sen. John McCain, R-Ariz., to get the VA to cover the medical bills.

Three years later, when her husband turned 65, she told him there was no longer any reason for him to go to the VA. She signed him up for Medicare, she said, but he still liked the VA.

Late last summer, Dennis, then 66, started feeling bad and began calling the VA to get an appointment with his primary care doctor. After about eight weeks and no appointment, the couple went to the ER at the VA. Dennis was seen immediately, she said, and the doctors did blood tests and took a chest X-ray. They discovered he was extremely anemic and admitted him for six or eight hours to administer iron directly into his blood.

But he didn’t get better. Early the next week he got a call from the VA saying he might have pneumonia. They sent him to a VA clinic closer to home for a second X-ray. He was given antibiotics, but he still felt bad.

Finally, Lynn decided to take her husband back to the civilian hospital. Within 12 hours, he was diagnosed with Stage IV lung cancer, she said. He died 21 days later.

“I’m convinced they never looked at the X-rays,” she said of the VA.

She acknowledges that it might have been too late to save her husband even if the doctors had found the cancer when they went to the VA emergency room in August. But, she said, the couple would have had time to make plans. Instead, he was nearly unconscious by the time he came home from the hospital 15 days after the diagnosis, and he died less than a week later.

“He just totally disintegrated,” she said. “I was not prepared to lose Dennis in five days.”

‘He stayed loyal to the military’

Navy veteran Dennis Richardson had struggled with post-traumatic stress and survivor syndrome since he returned from Vietnam, his brother Darrell said.

“But he stayed loyal to the military,” he said, and was proud to get his care at the VA.

Dennis Richardson split his time between Wisconsin and Arizona. When he was diagnosed with liver cancer by a civilian doctor in Wisconsin in late July 2012, he decided to get his treatment from the VA in Arizona.

He hand-carried his medical records and diagnosis to Phoenix, but when he tried to get an appointment with his primary care doctor at the VA so he could be referred to oncology, he was told he would have to wait seven months, his brother said.

“They wouldn’t even look at his records,” Darrell Richardson said. Family members tried calling to get him an appointment, but had no luck.

Richardson waited about three months, until he could no longer stand the pain. At the end of September 2012, he went to the VA emergency room and doctors started him on chemotherapy, but it was too late, his brother said. Dennis Richardson stopped chemo after a few weeks, saying he was simply too sick to handle it. He died Nov. 8, 2012, at the age of 65.

Darrell Richardson said he later found out that the Houston VA has one of the best liver cancer treatment programs in the country. If his brother had gotten a transfer to that program when he first arrived in Phoenix, he said, maybe he could have lived longer.

‘You have to be almost dead’

Carolyn Stoor struggled to hold back tears as she recounted the two times she said she almost lost her husband, Ken, in the past year.

“You have to be almost dead for them to do something” at the Phoenix VA clinics, she said.

Ken Stoor served in the Army from 1965 to 1969, and suffers from medical issues including diabetes, heart problems, PTSD and pre-cancerous tumors in his bladder, she said. He has been going to a VA clinic in Phoenix for about three years, even though it is about 65 miles away from their home in Superior, Ariz.

Ken Stoor kept his arm around her shoulders at the meeting, as she talked about how they have struggled to get him help.

In October, she took him to his primary care doctor with low blood pressure and a high fever. The doctor told her to take him home and “pump him full of fluids.”

She said she had already done that, so she took him to a civilian hospital, where doctors diagnosed him with a severe infection.

“They said, ‘We don’t know if he’s going to make it,'” Carolyn said, now crying.

After that, she requested a different primary care doctor for her husband.

“I actually told that last primary doctor what a rotten job she did: ‘Thank you very much but you almost killed him,'” she said. “I should have moved him out of the whole clinic,” she said, but they both really like the physician’s assistant he sees for his heart.

In April, Ken was having severe chest pains and Carolyn took him to the VA. He and six others were waiting for a test when the machine went down, she said.

They left to go to the civilian hospital, where doctors told her Ken was having a heart attack and might not survive.

“I just said, ‘I’m not letting him die on me,'” she said. “I’m not going to lose him over something stupid” like a broken machine.

Forgotten on the 4th floor

Robert Sertich served in the Air Force from 1947 to 1961. He went to the VA hospital in 2011 after being diagnosed with sepsis. His daughter, Kim Sertich, said doctors told her that he might be there for a few weeks.

He was 81, with underlying health issues, but she said he was coherent and could move around when she left him the first night.

By the second night, he was no longer coherent. She said she walked in to find him sitting in the dark, with his oxygen tube pinched under the wheels of his chair.

Doctors had requested an MRI to find the source of the infection, and he was put on a breathing machine in the intensive-care unit for a few days. He never got the test, she said.

When he started having trouble swallowing, the doctors put in a feeding tube.

One night, Robert pulled out the tube in his sleep. Kim gave permission for his hands to be loosely secured when he slept, so he couldn’t pull it out. Then he was moved to a different floor, Kim said, and the problems began adding up.

The MRI was never done, she said, and though a test of his swollen arm had been ordered on the third floor, the staff on the fourth floor never did it. They also refused to secure his hands, she said, and when he pulled the tube out, they wouldn’t put it back in.

Kim tried to feed her father, she said, but he could barely swallow. After a few days, Kim insisted they put the feeding tube back in. She paid for someone to watch her father 24 hours a day so he wouldn’t pull it out.

Her father’s blood tests were improving and he was getting more coherent, Kim said, but his arm continued to swell. When doctors realized it was a blood clot and began giving him blood thinners, “that was pretty much the end,” she said.

Robert Sertich died Nov. 14, 2011, after 33 days in the VA hospital. A week later, the hospital sent a condolence letter for “Richard Sertich.”

They keep coming back

Despite having serious problems with their care, many veterans return to the VA again and again for myriad reasons.

Stoor said her husband continues to go to the VA, where he has appointments and therapy a few times a week and gets many of his medications.

“It’s kind of scary, every time you go,” she said. “But if you don’t go, then you don’t get your benefit.”

Richardson said his brother always “stayed loyal to the military,” he said, and was proud to get his care at the VA, even with a cancer diagnosis, access to the Mayo Clinic and a seven-month wait for a referral.

Lynn Morris said she never really liked the VA, but her husband, Dennis, insisted on going there.

“The waiting room was horrendous,” she said, “and the attitude of the people working there was even worse.”

Still, he had served in the Army and liked his doctors at the VA, she said.

When he turned 65, his wife signed him up for Medicare, she said, but he still went to the VA.

She didn’t understand.

The emergency room was full of people with their heads between their legs because they were in such intense pain, she said. Foote said the average wait time there was frequently 12 to 16 hours.

“I thought it was a horrible mess from Day 1,” she said.

Robert Sertich lived nearly 90 miles from Phoenix, in Payson, Ariz., but going to the VA was “like this badge of honor,” his daughter Kim said.

The hospital floors were filthy, she said, and there were several days when the bathrooms for visitors and the hot water for patient showers didn’t work.

Young, the interim director of the Phoenix VA system, told the crowd he didn’t have answers for the veterans and families. But he stayed at the meeting for hours and took notes.

“I’m just here to listen and understand,” he said. “I don’t have the perfect solution yet.”

http://www.military.com/daily-news/2014/05/17/vets-using-phoenix-va-are-angry-sick-and-scared.html?ESRC=todayinmil.sm

Background Articles and Videos

United States Department of Veterans Affairs

The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system withCabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense.[1] With a total 2009 budget of about $87.6 billion, VA employs nearly 280,000 people at hundreds of Veterans Affairs medical facilities, clinics, and benefits offices and is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors. In 2012, the proposed budget for Veterans Affairs was $132 billion. [2] The VA 2014 Budget request for 2014 is $152.7 billion. This includes $66.5 billion in discretionary resources and $86.1 billion in mandatory funding. The discretionary budget request represents an increase of $2.7 billion, or 4.3 percent, over the 2013 enacted level.[3]

It is administered by the United States Secretary of Veterans Affairs.

History

The Continental Congress of 1776 encouraged enlistments during the American Revolutionary War by providing pensions for soldiers who were disabled. Direct medical and hospital care given to veterans in the early days of the republic was provided by the individual states and communities. In 1811, the first domiciliary and medical facility for veterans was authorized by the federal government, but not opened until 1834. In the 19th century, the nation’s veterans assistance program was expanded to include benefits and pensions not only for veterans, but also their widows and dependents.

VA Medical Center in ManhattanNew York City

After the Civil War, many state veterans’ homes were established. Since domiciliary care was available at all state veterans homes, incidental medical and hospital treatment was provided for all injuries and diseases, whether or not of service origin. Indigent and disabled veterans of the Civil War, Indian WarsSpanish-American War, and Mexican Border period as well as discharged regular members of the Armed Forces were cared for at these homes.

Congress established a new system of veterans benefits when the United States entered World War I in 1917. Included were programs for disability compensation, insurance for servicepersons and veterans, and vocational rehabilitation for the disabled. By the 1920s, the various benefits were administered by three different federal agencies: the Veterans Bureau, the Bureau of Pensions of the Interior Department, and the National Home for Disabled Volunteer Soldiers.

The establishment of the Veterans Administration came in 1930 when Congress authorized the president to “consolidate and coordinate Government activities affecting war veterans”. The three component agencies became bureaus within the Veterans Administration. Brigadier General Frank T. Hines, who directed the Veterans Bureau for seven years, was named as the first Administrator of Veterans Affairs, a job he held until 1945.

The close of World War II resulted in not only a vast increase in the veteran population, but also a large number of new benefits enacted by Congress for veterans of the war. In addition, during the late 1940s, the VA had to contend with aging World War I veterans. During that time, “the clientele of the VA increased almost five fold with an addition of nearly 15,000,000 World War II veterans and approximately 4,000,000 World War I veterans”.[4] Prior to World War II, in response to scandals at the Veterans Bureau, programs that cared for veterans were centralized in Washington, D.C. This centralization caused delays and bottlenecks as the agency tried to serve the World War II veterans. As a result, the VA went through a decentralization process, giving more authority to the field offices.[5]

The World War II GI Bill, signed into law on June 22, 1944, is said[by whom?] to have had more impact on the American way of life than any law since the Homestead Act nearly a century before.

The VA health care system has grown from 54 hospitals in 1930 to include 171 medical centers; more than 700 outpatient, community, and outreach clinics; 126 nursing home care units; and 35 domiciliaries. VA health care facilities provide a broad spectrum of medical, surgical, and rehabilitative care. The responsibilities and benefits programs of the Veterans Administration grew enormously during the following six decades.

Further educational assistance acts were passed for the benefit of veterans of the Korean War, the Vietnam Era, the introduction of an “all-volunteer force” in the 1970s (following the end of conscription in the United States in 1973), the Persian Gulf War, and those who served following the attacks of September 11, 2001.

The Department of Veterans Affairs Act of 1988 (Pub.L. 100-527) changed the former Veterans Administration, an independent government agency established in 1930, primarily to see to the needs of World War I veterans, into a Cabinet-level Department of Veterans Affairs. It was signed into law by President Ronald Reagan on October 25, 1988, but actually came into effect under the term of his successor, George H. W. Bush, on March 15, 1989.

The Department of Veterans Affairs was created due to nearly one third of the population being eligible for veterans benefits. Its proponents argued that due to the large number of Americans affected by the VA, it needed an administrator who had direct access to the president.[6]

In their major reform period of 1995–2000, the Veterans Health Administration (VHA) implemented universal primary care, closed 55% of their acute care hospital beds, increased patients treated by 24%, had a 48% increase in ambulatory care visits, and decreased staffing by 12%. By 2000, the VHA had 10,000 fewer employees than in 1995 and a 104% increase in patients treated since 1995, and had managed to maintain the same cost per patient-day, while all other facilities’ costs had risen over 30% to 40% during the same period.

VA Medical Center in Palo Alto, California

Functions

The Department of Veterans Affairs is headed by the Secretary of Veterans Affairs, appointed by the President with the advice and consent of the Senate. The current Secretary of Veterans Affairs is Retired Army General Eric Shinseki.

Its primary function is to support Veterans in their time after service by providing benefits and support. A current initiative in the Department is to prevent and end Veterans’ homelessness.[7] The VA works with the United States Interagency Council on Homelessness to address these issues. Shinseki sits on the Council and is committed to ending Veteran’s homelessness by 2015 as laid out in Opening Doors: Federal Strategic Plan to Prevent and End Homelessness, released in 2010.[8]

The Department has three main subdivisions, known as Administrations, each headed by an Undersecretary:

  • Veterans Health Administration (VHA): responsible for providing health care in all its forms, as well as for biomedical research (under the Office of Research and Development), Community Based Outpatient Clinics (CBOCs), and Regional Medical Centers
  • Veterans Benefits Administration (VBA): responsible for initial veteran registration, eligibility determination, and five key lines of business (benefits and entitlements): Home Loan Guarantee, Insurance, Vocational Rehabilitation and Employment, Education (GI Bill), and Compensation & Pension
  • National Cemetery Administration: responsible for providing burial and memorial benefits, as well as for maintenance of VA cemeteries

Benefits

The benefits provided include disability compensation, pension, education, home loans, life insurance, vocational, rehabilitation, survivors’ benefits, medical benefits, and burial benefits.[9] The VA currently breaks down benefits in a benefits booklet.[10] Benefits and topics include; VA Health Care Benefits, Veterans with Service-Connected Disabilities, VA Pensions, Education and Training, Home Loan Guaranty, VA Life Insurance, Burial and Memorial Benefits, Reserve and National Guard, Special Groups of Veterans, Transition Assistance, Dependents and Survivors Health Care, Dependents and Survivors Benefits, Appeals of VA Claims Decisions, Military Medals and Records, and Other Federal Benefits.

Costs for care

As is common in any time of war, recently there has been an increased demand for nursing home beds, injury rehabilitation, and mental health care. VA categorizes veterans into eight priority groups and several additional subgroups, based on factors such as service-connected disabilities, and one’s income and assets (adjusted to local cost of living).

Veterans with a 50% or higher service-connected disability as determined by a VA regional office “rating board” (e.g., losing a limb in battle, PTSD, etc.) are provided comprehensive care and medication at no charge. Veterans with lesser qualifying factors who exceed a pre-defined income threshold have to make co-payments for care for non-service-connected ailments and pay $9 per 30-day supply for each prescription medication. VA dental and nursing home care benefits are more restricted.

VA Medical Center in Long Beach, California

Reservists and National Guard personnel who served stateside in peacetime settings or have no service-related disabilities generally do not qualify for VA health benefits.[11]

VA’s budget has been pushed to the limit in recent years by the War on Terrorism.[12] In December 2004, it was widely reported that VA’s funding crisis had become so severe that it could no longer provide disability ratings to veterans in a timely fashion.[13] This is a problem because until veterans are fully transitioned from the active-duty TRICARE healthcare system to VA, they are on their own with regard to many healthcare costs.

The VA’s backlog of pending disability claims under review (a process known as “adjudication”) peaked at 421,000 in 2001, and bottomed out at 254,000 in 2003, but crept back up to 340,000 in 2005.[14]

No copayment is required for VA services for veterans with military-related medical conditions. VA-recognized service-connected disabilities include problems that started or were aggravated due to military service. Veteran service organizations such as the American LegionVeterans of Foreign Wars, and Disabled American Veterans, as well as state-operated Veterans Affairs offices and County Veteran Service Officers (CVSO), have been known to assist veterans in the process of getting care from the VA.

In his budget proposal for fiscal year 2009, President George W. Bush requested $38.7 billion—or 86.5% of the total Veterans Affairs budget—for veteran medical care alone.

In the 2011 Costs of War report from Brown University, researchers projected that the cost of caring for veterans of the War on Terror would peak 30–40 years after the end of combat operations. They also predicted that medical and disability costs would ultimately total between $600 billion and $1 trillion for the hundreds of thousands treated by the Department of Veterans Affairs.[15]

The New GI Bill

The new GI Bill authored by Sen. Jim Webb (D-VA) doubled GI Bill college benefits while providing a 13-week extension to federal unemployment benefits. The new GI Bill doubled the value of the benefit to roughly $90,000 up from $40,000. In-state public universities essentially are covered to provide full scholarships for veterans under the new education package. For those veterans who served at least three years a monthly housing stipend was also added to the law.

Upon passage of the new GI Bill President George W. Bush stated “Our nation has no greater responsibility than to support our men and women in uniform—especially because we’re at war… This bill shows the American people that even in an election year, Republicans and Democrats can come together to support our troops and their families”, which highlighted that the new GI Bill had been overwhelmingly supported by both parties in the U.S. Congress.[16]

Congress and President Barack Obama extended the new GI Bill in August of 2009 at the cost of roughly $70 billion over the next decade. Upon passing the GI Bill extension President Obama stated his support of the fighting forces of the United States by saying “Over the last eight years, they have endured tour after tour of duty in dangerous and distant places… They’ve experienced grueling combat, from the streets of Fallujah to the harsh terrain of Helmand province. They’ve adapted to complex insurgencies, protected local populations and trained foreign security forces.”

The Pentagon worked closely with Congressional lawmakers to ensure military families were protected in the expansion of the law. In doing so, military officials worked non-stop to add a provision to extend the GI Bill to the surviving spouse and children of servicemembers killed while in combat.

This provision was highly favored by the Pentagon which authorized the Department of Defense (DoD) to allow individuals who, on or after August 1, 2009, have served at least 6 years in the Armed Forces and who agree to serve at least another 4 years in the U.S. Armed Forces to transfer unused entitlement to their surviving spouse. Servicemembers reaching 10 year anniversaries could choose to transfer the benefit to any dependent(s) (spouse, children).[17]

National Cemetery Administration

In 1973, the Veterans Administration assumed another major responsibility when the National Cemetery System (NCS) (except for Arlington National Cemetery) was transferred to the Veterans Administration from the Department of the Army.

The VA was charged with the operation of the NCS, including the marking of graves of all persons in national and State cemeteries (and the graves of veterans in private cemeteries, upon request) as well and administering the State Cemetery Grants Program. The VA’s National Cemetery Administration maintains 131 national cemeteries in 39 states (and Puerto Rico) as well as 33 soldier’s lots and monument sites.

The Department of the Army maintains two national cemeteries, the Arlington National Cemetery and the U.S. Soldiers’ & Airmen’s Home National Cemetery. Many states have established state veterans cemeteries. The American Battle Monuments Commission maintains 24 overseas military cemeteries that serve as resting places for almost 125,000 American war dead; on Tablets of the Missing that memorialize more than 94,000 U.S. servicemen and women; and through 25 memorials, monuments and markers.

Fourteen national cemeteries are maintained by the National Park Service.

Related legislation

See also

Notes and references

  1. Jump up^ [1] USA.GOV
  2. Jump up^ [2] VA Press Release 2011
  3. Jump up^ [3] VA.gov
  4. Jump up^ Kammerer, Gladys 1948. “The Veterans Administration in Transition”. Public Administration Review Vol. 8, No. 2, pp 104.
  5. Jump up^ Kammerer, Gladys 1948. “The Veterans Administration in Transition”. Public Administration Review Vol. 8, No. 2, pp. 103–109.
  6. Jump up^ http://www.va.gov/opa/publications/archives/docs/history_in_brief.pdf
  7. Jump up^ [4]
  8. Jump up^ Opening Doors | United States Interagency Council on Homelessness (USICH). Usich.gov (2010-06-22). Retrieved on 2013-07-23.
  9. Jump up^ Benefits: Links, US Department of Veterans Affairs, Retrieved May 26, 2007
  10. Jump up^ [5] Federal Benefits for Veterans, Dependents and Survivors
  11. Jump up^ Detailed list of VA eligibility criteria
  12. Jump up^ Dennis Camire, “New fees, limits face ailing veterans,” Albany Times Union, 10 February 2003, A1.
  13. Jump up^ Cheryl L. Reed, “VA chief orders inspector to probe disability rating system,”Chicago Sun-Times, 11 December 2004, A3.
  14. Jump up^ Cory Reiss, “VA fighting losing battle against backlog of veterans’ claims”,Sarasota Herald-Tribune, 27 May 2005, A7.
  15. Jump up^ “Caring for US Veterans”Costs of War. Brown University. Retrieved 19 July 2011.
  16. Jump up^ [6] President Bush Signs GI Bill
  17. Jump up^ [7] Post-911 GI Bill Transferability Fact Sheet

Further reading

In 1998, the Institute of Medicine began a series of studies to respond to requests from the U.S. Department of Veterans Affairs and Congress for an examination of the health effects of potentially harmful agents to which Gulf War veterans might have been exposed.

External links

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