The case for mandating health insurance reform june 2016

The case for mandating health insurance reform

, “improving health and health care: an agenda for reform,” p.^ "how to access health care – massachusetts uncompensated (free) care pool"..gov/sites/default/files/114th-congress-2015-2016/reports/51180-2016outlooktestimony_hbc.[2] section 1557 reads:[a]n individual shall not, on the ground prohibited under title vi of the civil rights act of 1964, title ix of the education amendments of 1972, the age discrimination act of 1975, or section 794 of title 29, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving federal financial assistance, including credits, subsidies, or contracts of insurance, or under any program or activity that is administered by an executive agency or any entity established under this title. offers for purchase health insurance plans for individuals who:Are employed by a small business (less than 50 employees) that uses the connector to offer health insurance. specifically, under this new rule, refusals by health plans to cover “gender transition” (commonly known as “sex change”) treatments may be determined by hhs to constitute impermissible discrimination under federal civil rights laws. for good measure, congress should clarify that section 1557 also may not be interpreted as altering the existing application of civil rights statutes to federally recognized indian tribes, tribal organizations, and the indian health service. the plaintiffs asserted that gilead discriminated against the disabled because it charged more for its drugs to people in the united states than it charged abroad, charged more for individuals who are not part of health programs or plans that received discounts, caused health plans and programs to refuse access to its drugs, and denied access itself because of “excessive and discriminatory pricing practices, contracts and policies.” in essence, the obama administration is asserting that, under the guise of enforcing “non-discrimination,” the hhs office for civil rights has the power to impose coverage mandates on private health plans and to determine what constitutes appropriate medical practice.[120] the controversial board has been defunded for 2016 under the consolidated appropriations act for 2016. for example:In june 2015, the cbo said that the law’s combination of subsidies, taxes, and medicaid expansions would “discourage” work.” thus, section 1557 could be turned into a tool for detailed federal regulation of prescription drug formulary designs in employer and insurer health plans. back in may of 2015, law professor timothy jost wrote about three cases involving section 1557 claims in which federal district court judges had already handed down decisions. first, employers are deemed to have offered "fair and reasonable" coverage if at least 25% of their full-time workers are enrolled in the firm's health plan. over the period from 2013 to 2015, medicaid spending increased by 32 percent, according to the cbo; it will increase by 9 percent in 2016, and only then will medicaid spending growth begin to taper off.[99] congressional budget office, “payments of penalties for being uninsured under the affordable care act: 2014 update,” june 2014, table 1, “estimated distribution of individual mandate penalties under the affordable care act, calendar year 2016,” https://www.” they also envisioned big reductions in employer and employee insurance costs that would have a direct, positive impact on ordinary americans: “the typical family will save 00 per year. another policy paradox, progressive health reformers have routinely complained that americans spend too much on health care but have embraced a legislative remedy that substantially guarantees ever greater health care spending.[37] for the vast majority of americans still enrolled in the huge employment-based health insurance markets, the office of the actuary at the centers for medicare and medicaid services reported in april 2010 that the health law’s new taxes on health insurance, drugs, and medical devices would also translate into higher group insurance premiums. it performed the following functions:It administers the commonwealth care program for low-income residents (up to 300% of the fpl) who do not qualify for masshealth[26] and who meet certain eligibility guidelines.[27] in 2016, based on official estimates, approximately 90 percent of an estimated 30 million uninsured would not be forced to pay the penalty because of multiplying exemptions. result: virtually every major decision in the health care sector of the american economy is either made or constrained, directly or indirectly, by federal officials.[126] congressional budget office, the budget and economic outlook: 2016 to 2026, p. tax credits under title i of the aca, as well as payments, subsidies, or other funds extended by the department to any entity providing health insurance coverage for payment to or on behalf of an individual obtaining health insurance coverage from that entity or extended by the department directly to such individual for payment to any entity providing health insurance coverage. the key change would entail giving all persons a direct and simpler system of individual tax relief for the purchase of the health insurance of their choice, whether group or non-group coverage.[44] it should be noted that these blue cross carriers do participate in the federal employees health benefits program. and it makes it easier for insurance companies to treat their customers badly—by cherry-picking the healthiest individuals and trying to drop the sickest, by overcharging small businesses that have no leverage, and by jacking up rates.[93] congressional budget office, private health insurance premiums and federal policy, p.[82] author’s calculations based on aggregate and per capita data from centers for medicare and medicaid services, office of the actuary, “table 3: national health expenditures; aggregate and per capita amounts, percent distribution and annual percent change by source of funds: calendar years 2008–2024,” july 22, 2015, https://www.[45] approximately 1% of taxpayers were determined by the commonwealth to have had access to affordable insurance during tax year 2009 (latest data available), and had to pay an income tax penalty instead.: healthcare in massachusettsmedicare and medicaid (united states)universal healthcaremitt romneyhealth insurance marketplaceshealthcare reform in the united states by statehidden categories: articles to be expanded from january 2015articles with specifically marked weasel-worded phrases from march 2014all articles with unsourced statementsarticles with unsourced statements from november 2013articles with unsourced statements from june 2010. 2013, the obama administration provided special taxpayer subsidies for members of congress and staff to offset their higher insurance costs in the aca health insurance exchange. the 2006 massachusetts law successfully covered approximately two-thirds of the state's then-uninsured residents, half via federal-government-paid-for medicaid expansion (administered by masshealth) and half via the connector's free and subsidized network-tiered health care insurance for those not eligible for expanded medicaid.” although administration officials believed that their delivery reforms—such as “value based purchasing” for hospitals and “pay for performance” for physicians—would be both cost-effective and productive, in 2010, the cbo declined to score them as having any effect on health care spending. timothy jost of washington and lee university and harold pollack of the university of chicago, prominent academic supporters of the aca, nonetheless acknowledge: “the aca undertook from the beginning an ambitious reform agenda, but some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems. fact, the aca authorizes federal funding of abortion in its “qualified” health plans, a sharp break from previous law. manner in which this proposed rule would regulate health plans and providers is most clearly illustrated by the administration’s inclusion in the rule of provisions that explicitly apply to one particular psychological condition.. department of health and human services, centers for medicare and medicaid services, office of the actuary, may, 18, 2012, p. its face, section 1557 prohibits discriminatory actions that prevent an individual participating in, or receiving public assistance for, federally funded health care coverage for which the individual otherwise qualifies. for instance, the plaintiffs’ argument in the gilead case that individuals with hepatitis c are disabled, and thus protected from “price discrimination” under section 1557 could be deployed to challenge plan reimbursement policies for drugs to treat hepatitis c—or any other medical condition that federal regulators or judges could be persuaded constitutes a “disability. under this approach, for example, a health plan would not be permitted to place all the medications required to treat a particular health condition on the most expensive tier in the plan’s prescription-drug formulary. at the end of the month, the joint committee on health care financing approved a reform proposal crafted by house speaker dimasi, committee co-chair patricia walrath, and other house members. march 2012, the national bureau of economic research released a working paper stating "that health care reform in massachusetts led to better overall self-assessed health.[43] the cbo recently confirmed this general upward trend: “insurance premiums—the payments made to buy that coverage by enrollees or by other parties on their behalf—are high and rising. more than half of the law’s nonprofit co-op health plans, heavily financed with taxpayer-backed loans and designed to enhance competition in the exchanges, have collapsed. 2006, the number of uninsured massachusetts residents dropped from about 6% to about 2% in 2010 according to the massachusetts department of healthcare finance and policy (dhcfp), depending on the methodology used,[44] according to the massachusetts center on health information and analsysis (chia), which replaced the dhcfp in 2012, the percentage of uninsured rose back to between 3–4% in 2012. key question is whether persons subject to this higher tax penalty would have an incentive to pay it and forgo coverage or whether it would encourage persons to enroll in the coverage in the government’s health insurance exchanges. health insurance, congress should take specific steps to allow personal, portable, and affordable health coverage to flourish. tax credits under title i of the aca, as well as payments, subsidies, or other funds extended by the department to any entity providing health insurance coverage for payment to or on behalf of an individual obtaining health insurance coverage from that entity or extended by the department directly to such individual for payment to any entity providing health insurance coverage. federal departments are mostly responsible for the issuance of aca regulations: the department of health and human services, the department of labor, and the department of the treasury, particularly the internal revenue service (irs).[42] the source to the below list of available plans is via the massachusetts health connector —[43]. thus asserted that “expectations that gender can only be constructed within two distinct opposite and disconnected forms (masculinity and femininity)” is a form of “sex stereotyping,” constituting impermissible discrimination “on the basis of sex,” hhs proceeds to specify in the proposed rule that “a covered entity shall not,” among other things:Categorically or automatically exclude from coverage, or limit coverage for, all health services related to gender transition; or otherwise deny or limit coverage, or deny a claim, for specific health services related to gender transition if such denial or limitation results in discrimination against a transgender individual. 2013, the obama administration provided special taxpayer subsidies for members of congress and staff to offset their higher insurance costs in the aca health insurance exchange."chapter 324 of the acts of 2006, an act relative to health care access".[134] under section 1312 d of the affordable care act, congress voted itself out of its existing insurance coverage and required most members and staff to get coverage in the exchange. in 2013, there were 395 insurers operating in the non-group market; in 2015, there were 307; but in 2016, there are only 287. the process of merging the two markets also froze the market for such insurance for a short period in april–may 2010 as the current government tried to keep the leading non-profit insurers, which insure over 90% of the residents, in the state from raising premiums for small businesses and individuals. “although health care spending grew more slowly in the past several years than it has historically,” the cbo reports, “over the coming decade, per-enrollee spending in federal health programs will grow more rapidly than it has in recent years. first, hhs defines a “covered entity” subject to the regulations as an “entity that operates a health program or activity, any part of which receives federal financial assistance., the federal government’s website for enrollment in the health insurance exchanges. august 20, 2009, president obama said, “there are no plans under health reform to revoke the existing prohibition on using federal taxpayer dollars for abortions. federal officials enforce rules governing insurance rating, co-payments and deductible levels, and allowable profit and administrative expenses.

The case for mandating health insurance reform june 2016

” furthermore, it is also clear from the first paragraph that hhs considers its office for civil rights’ opinion of what is “medically necessary” to be superior to the opinions of health plans. january 2016, the cbo again projected a decline in labor force participation and a negative impact on economic growth:Cbo anticipates that several developments in federal fiscal policy under current law will affect the economy through their impact on the labor market. for many persons, the trade-off is perfectly reasonable, but the law imposes costly comprehensive benefit requirements and insurance rules, so for many middle-income persons, given that there is no legal alternative, the choice of insurance is constrained. civil rights statutes already guarantee all americans access to any federal health care program or subsidy for which they otherwise qualify., though the employer mandate has been a staple of the progressive health policy agenda for decades, prominent health policy analysts, such as those at the urban institute, have recently expressed reservations about it and have called for its repeal."[61] the authors note that the "results show that health care reform has implications that extend well beyond the health of those who gain insurance coverage. fundamentally, they are problems of legislative design, particularly in the regulation of health insurance:An overly complex system of excessive insurance subsidies,Health benefit mandates and rating rules that greatly increase health insurance costs, and..gov/sites/default/files/114th-congress-2015-2016/reports/51130-health_insurance_premiums_onecol..gov/sites/default/files/114th-congress-2015-2016/reports/49974-outlook_senate_qfr. congressional budget office, private health insurance premiums and federal policy, p. with medicaid, congress could likewise create a strong “premium support” or defined-contribution system that would mainstream low-income persons into the private health insurance markets.. department of health and human services, centers for medicare and medicaid services, office of the actuary, april 22, 2010, https://www. "the effects of the massachusetts health reform on household financial distress". for millions of americans, the most costly insurance mandates and regulations affect their coverage., while the obama administration had to resort to devising a contorted reinterpretation of the concept of sex discrimination to justify mandating coverage for “gender transition” treatments, the concept of “disability” (another category of prohibited discrimination under section 1557) is already sufficiently broad that the federal government could easily use it to justify imposing similar coverage and treatment mandates in other circumstances. in those cases, attorneys for the parents of children with cystic fibrosis convinced federal judges to order that the children be added to the adult lung transplant waiting list (for patients age twelve and older), instead of remaining on the pediatric transplant waiting list—raising a number of concerns among medical ethicist and clinicians.” sara rosenbaum, “a ‘broader regulatory scheme’—the constitutionality of health care reform,” the new england journal of medicine, vol.[62] the appeals court then heard the appeal and declined to send the case back to essex superior court for trial by jury based on their belief that no facts needed to be determined and therefore trial by jury in this case was not a protected right under either the us or massachusetts constitutions. for example:Reason #1: despite the president’s repeated promises, rising insurance costs continue to burden businesses and families. "massachusetts health reforms: uninsurance remains low, self-reported health status improves as state prepares to tackle costs".[82] author’s calculations based on aggregate and per capita data from centers for medicare and medicaid services, office of the actuary, “table 3: national health expenditures; aggregate and per capita amounts, percent distribution and annual percent change by source of funds: calendar years 2008–2024,” july 22, 2015, https://www. those 164 million americans have coverage that is issued or administered by one of 181 insurance companies that would be subject to this regulation because those insurers also provide coverage to other individuals under federally subsidized aca exchange plans, medicare advantage plans, or medicaid managed-care contracts. title i, federal officials define the content of health insurance coverage, including required medical treatments, procedures, and preventive health care services. simultaneously “bending the cost curve” downward and increasing insurance enrollment and government subsidies would have been a neat trick[79] for a law that created new federal entitlements and thus became a powerful engine of massive future federal spending.[128] in the case of the special “multi-state health plans” administered by the opm, the law requires the federal government, beginning in 2014, to contract with at least two national health plans, one of which must offer abortion coverage in the aca exchanges. the key change would entail giving all persons a direct and simpler system of individual tax relief for the purchase of the health insurance of their choice, whether group or non-group coverage.[42] healthpocket, a national firm comparing rates and benefits, reports that insurers in 45 states have requested an average premium rate increase of 12 percent. commonwealth of massachusetts passed a health care reform law in 2006 with the aim of providing health insurance to nearly all of its residents. family foundation researchers, for example, estimate that one in four employers offering health benefits would be affected. obama said that his health reform proposal would not add “a dime” to the federal deficit and insisted from the inception of the debate that the final product would drive down the deficits and be a triumph of fiscal responsibility. the health insurance subsidies that the act provides through the expansion of medicaid and the exchanges are phased out for people with higher income, creating an implicit tax on some people’s additional earnings. the number of people with group insurance in massachusetts has held steady at around 4,400,000 since passage of the health care reform law, according to the dhcfp's quarterly key indicators reports available on its website.” the final rule should define “benefit design” as including, but not limited to, the following specific elements: prescription drug formularies; health care provider networks (including access to specialists and pharmacy access); wellness programs; tiered coverage and cost-sharing structures for drug formularies and provider networks; cost-sharing charges (including co-payments, co-insurance, deductibles, and other charges enrollees pay for health care items and services); utilization management; quantitative treatment limits; and non-quantitative treatment limits including prior authorization and step therapy.[citation needed] according to the dhcfp's quarterly key indicator reports, 89,000 people bought healthcare insurance directly as of june 2009, up from 40,000 in june 2006.[6] in fact, the prospect of rising costs, disruption of existing coverage, and metastasizing bureaucracy—dynamics that also doomed the medicare catastrophic coverage act of 1988 and undermined the clinton health plan of 1993—have characterized the aca’s rocky implementation.[9] the temporary slowdown in health spending, which started in the early 2000s, is over, and businesses, individuals, and families are once again threatened with higher health care costs. as such it is one of the models of the affordable care act's health insurance exchanges. any new health reform agenda, congress cannot ignore the major federal health entitlements.”[46] she went on to note that one effect is to turn health insurance into “a regulated industry…that, in its restructured form, will therefore take on certain characteristics of a public utility. as the cbo has noted, “operating in a more competitive market gives insurers a stronger incentive to limit the premiums that they charge and to constrain their administrative costs and profits—but in many parts of the united states, insurance markets are not very competitive. this rule also constitutes an assertion of federal authority over the professional medical judgments of health care providers that is both undesirable and unwarranted. in 2010, sara rosenbaum, a prominent supporter of the aca, tellingly delinated that larger issue when she wrote, “first, and perhaps most fundamentally, in a remarkable shift whose precedent lies in the watershed civil rights act of 1964, the aca transforms health insurance into a public accommodation.[2] section 1557 reads:[a]n individual shall not, on the ground prohibited under title vi of the civil rights act of 1964, title ix of the education amendments of 1972, the age discrimination act of 1975, or section 794 of title 29, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving federal financial assistance, including credits, subsidies, or contracts of insurance, or under any program or activity that is administered by an executive agency or any entity established under this title. also the law’s government health insurance exchanges, heavily regulated and federally supervised health insurance mechanisms that are markedly different in goals and functions from market-based exchanges. major revisions related to health care industry price controls were passed in august 2012, and the employer mandate was repealed in 2013 in favor of the federal mandate (even though enforcement of the federal mandate was delayed until january 2015). however, this proposed rule would apply only to health programs and activities any part of which receives federal financial assistance from hhs.[118] other revenues crucial to the aca’s deficit-reduction potential are its increasingly unpopular taxes such as the cadillac tax, medical device tax, and health insurance tax. a plan’s “benefits” to encompass not only specific items or services, but also any limits on coverage or payment for specific items or services, would make numerous design features of public and private health plans subject to legal challenges under section 1557. under this approach, for example, a health plan would not be permitted to place all the medications required to treat a particular health condition on the most expensive tier in the plan’s prescription-drug formulary. consequently, the administration proposes to overrule, by regulatory fiat, the judgments of any health plans or medical professionals holding contrary views.[20] he vetoed eight sections of the health care legislation, including the controversial employer assessment., the administration is asserting that determinations by the hhs office for civil rights of what constitutes appropriate medical treatment will be imposed on health plans and medical providers by regulatory fiat.”[ 26] thus, it is not difficult to envision this legal theory being applied to health plans. the sheer magnitude of the aca’s insurance subsidies, it is odd that exchange enrollment is falling well short of official expectations. moffit, phd, is a senior fellow in the center for health policy studies, of the institute for family, community, and opportunity, at the heritage foundation.[28] the fair share contribution will be paid into the commonwealth care trust fund to fund commonwealth care and other health reform programs.. 3762, restoring americans’ healthcare freedom reconciliation act, as passed by the senate on december 3, 2015, and following enactment of the consolidated appropriations act, 2016,” january 4, 2016, https://www. that some state legislatures have already been persuaded to mandate that health insurers cover the foregoing items and services, it is not hard to imagine the hhs office for civil rights, or federal judges, applying the proposed rule to achieve the same results at the federal level. with certain statutory or administrative exceptions, all americans are legally required to provide or enroll in federally approved insurance coverage or pay a tax penalty for refusing to provide such coverage as an employer or to enroll in such coverage as an individual.[93] congressional budget office, private health insurance premiums and federal policy, p.[21] he vetoed provisions providing dental benefits to poor residents on the medicaid program, and providing health coverage to senior and disabled legal immigrants not eligible for federal medicaid. million would pay less for any penalty than they would to buy the least expensive insurance available to them.

The case for mandating health insurance

key question is whether persons subject to this higher tax penalty would have an incentive to pay it and forgo coverage or whether it would encourage persons to enroll in the coverage in the government’s health insurance exchanges. the connector acts as an insurance broker to offer free, highly subsidized and full-price private insurance plans to residents, including through its web site. to a 2016 study in the american economic journal, the reform "reduced the amount of debt that was past due, improved credit scores, reduced personal bankruptcies and reduced third-party collections. the legislation included a merger of the individual (non-group) insurance market into the small group market to allow individuals to get lower group insurance rates.[139] the top goal should be to empower individuals and families as the key decision-makers in the health care economy. in 2014, the cbo projected that approximately 4 million individuals would face the mandate penalty in 2016 and generate an estimated billion in revenues. 2014, narrower than anticipated networks in health insurance exchange plans and higher than expected deductibles resulted in lower plan premiums, which in turn reduced the cost of the federal insurance subsidies and thus overall projected aca spending. another analysis, researchers at the kaiser family foundation reported that the average annual growth in health care spending was 8. for good measure, congress should clarify that section 1557 also may not be interpreted as altering the existing application of civil rights statutes to federally recognized indian tribes, tribal organizations, and the indian health service.[53] for a brief survey of the professional literature, see congressional budget office, private health insurance premiums and federal policy, pp.. department of health and human services, office of the assistant secretary of planning and evaluation, aspe issue brief, march 3, 2016, p. this rule also constitutes an assertion of federal authority over the professional medical judgments of health care providers that is both undesirable and unwarranted. eventually the state's non-partisan insurance board ruled that the government did not have the actuarial data or right to freeze the premiums. analysis of enrollment data from insurer regulatory filings finds that, under these criteria, the regulation’s mandates would be imposed on the coverage of over 164 million americans with unsubsidized private individual or employer group health insurance. beyond the aca, federal health policies governing the pre-obamacare health care arrangements, particularly the insurance markets, were profoundly flawed. obama administration’s design for imposing more health care mandates. health insurers with multiple lines of business, including administering self-insured plans, that would mean deciding which market segments—subsidized or unsubsidized—they will serve, and restructuring their businesses accordingly. for instance, the plaintiffs’ argument in the gilead case that individuals with hepatitis c are disabled, and thus protected from “price discrimination” under section 1557 could be deployed to challenge plan reimbursement policies for drugs to treat hepatitis c—or any other medical condition that federal regulators or judges could be persuaded constitutes a “disability.[125] keith hall, director, congressional budget office, “the budget and economic outlook: 2016 to 2026,” testimony before the committee on the budget, u. million persons enrolled in the exchanges rather than the expected 11 million; for 2016, the cbo projects 13 million exchange enrollees, a big drop from the agency’s earlier projection of 21 million. analysis of enrollment data from insurer regulatory filings finds that, under these criteria, the regulation’s mandates would be imposed on the coverage of over 164 million americans with unsubsidized private individual or employer group health insurance. for 2016, exchange enrollments have already fallen below the cbo’s initial projections, as well as the projections of the administration, the urban institute, and the rand corporation. health connector is designed as a clearinghouse for insurance plans and payments. kaiser researchers estimated that the economic decline was responsible for 77 percent of the decrease in health spending growth during that period. law’s most publicized operational problems surfaced with the disastrous october 2013 rollout of healthcare. on the average, the globe reported, these part-time enrolees were paying ,200–,600 in premiums over a few months and receiving ,000 or more in healthcare services before again dropping coverage. these special subsidies are available only to enrollees who choose a silver-level health plan, which means that the plan must pay 70 percent of the average enrollee’s total medical expenses for covered benefits, with the enrollee paying the rest through deductibles and co-payments. in june, the national women’s law center filed administrative complaints with the hhs office for civil rights arguing that the exclusion of dependent pregnancy coverage under the employee health plans of five representative institutions constitutes impermissible discrimination under section 1557.[27] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. 58 had several key provisions: the creation of the health connector; the establishment of the subsidized commonwealth care health insurance program; the employer fair share contribution and free rider surcharge; and a requirement that each individual must show evidence of coverage on their income tax return or face a tax penalty, unless coverage was deemed unaffordable by the health connector.[30] sara rosenbaum, a prominent legal expert at george washington university, says as much: “the law fundamentally transforms health insurance from a product designed to preserve profitability in the face of rampant adverse selection to a regulated industry whose long-term strength and stability are essential to the public interest and that, in its restructured form, will therefore take on certain characteristics of a public utility. the defendant was a pharmaceutical company, not a health plan, and while the judge dismissed the case on other grounds—including that federal patent law grants pricing freedom to patent holders—the plaintiffs’ claims in this case offer a flavor of what insurers and benefit managers can expect under the proposed rule.[6] in fact, the prospect of rising costs, disruption of existing coverage, and metastasizing bureaucracy—dynamics that also doomed the medicare catastrophic coverage act of 1988 and undermined the clinton health plan of 1993—have characterized the aca’s rocky implementation. the health insurance subsidies that the act provides through the expansion of medicaid and the exchanges are phased out for people with higher income, creating an implicit tax on some people’s additional earnings.. 3762, restoring americans’ healthcare freedom reconciliation act, as passed by the senate on december 3, 2015, and following enactment of the consolidated appropriations act, 2016,” january 4, 2016, https://www. enactment of the aca, some overly exuberant administration allies quickly credited the newly minted law with a decline in the growth of health care spending. the judge dismissed the case upon a motion filed by an assistant to attorney general martha coakley for failure to state a case upon which relief can be granted., the administration is asserting that determinations by the hhs office for civil rights of what constitutes appropriate medical treatment will be imposed on health plans and medical providers by regulatory fiat.[93] many employers will doubtless scale back their health benefit offerings to avoid the tax. surprisingly, for sound philosophical reasons that are deeply rooted in america’s rich political culture of personal liberty, those americans who opposed enactment of the aca have expressed profound aversion to government control of their health care decisions. in addition the state spent a substantial amount of general revenue on the insurance reform."chapter 450 of the acts of 2006, an act further regulating health care access".[10] namarata uberoi, kenneth finegold, and emily gee, “health insurance coverage and the affordable care act, 2010–2016,” u. of all of the variables contributing to the slowdown, claim bradley herring of johns hopkins university and erin trish of the university of southern california, “the most important…appears to be the great recession’s effect on reduced real per capita income and the subsequent effect on reduced health care spending, as about 41% of the recent slowdown can be explained by these reductions in income. almost all people who did not have insurance could not afford it, but since they were still using the good it is considered free riding. the law mandated that nearly every resident of massachusetts obtain a minimum level of insurance coverage, provided free health care insurance for residents earning less than 150% of the federal poverty level (fpl) and mandated employers with more than 10 "full-time" employees to provide healthcare insurance. since the amendments passed, courts have more broadly interpreted “disability,” although they continue to assess each case individually. indeed, because this process started with what could be called a “hard case”—meaning one for which the administration had to creatively and laboriously extrapolate its desired conclusion from the underlying statute—should hhs establish a precedent on such tenuous grounds, it would become much easier to subsequently achieve similar results in other areas. back in may of 2015, law professor timothy jost wrote about three cases involving section 1557 claims in which federal district court judges had already handed down decisions. cbo analysts must try to account for a variety of unpredictable market shifts in insurance coverage that could go in any direction. consequently, the administration proposes to overrule, by regulatory fiat, the judgments of any health plans or medical professionals holding contrary views. fact, heritage foundation research has confirmed that the aca has not increased health plan competition.[82] on a per capita basis, based on cms data, total spending on health insurance will rise from ,786 in 2016 to ,681 in 2024. in either case, a sharp growth in health care spending, both public and private, is once again well underway. in either case, a sharp growth in health care spending, both public and private, is once again well underway. however, in the proposed regulation the obama administration further expansively interprets that already broad, statutory text to also apply those prohibitions to the benefits covered by health insurance plans, the treatments provided by medical professionals, and the health insurance coverage of tens of millions of americans enrolled in private, unsubsidized plans. president’s assertions that his policy would redirect the health cost trajectory downward were rooted in his presidential campaign advice. the cbo projects that it will remain at that level in 2016 and fall again to 62. one supporter, writing in health affairs, describes how that could occur:[a]nother way to achieve section 1557 protection against discrimination is for hhs or courts to categorize certain diseases as “disabilities. result: virtually every major decision in the health care sector of the american economy is either made or constrained, directly or indirectly, by federal officials. 2015, the cbo reported that medicare spending, which has an enormous influence on america’s health care economy, increased about 7 percent, the fastest rate of growth since 2009.^ bhi study: massachusetts health care reform drives up insurance costs both public and private beacon hill institute july 2011.

Health Care June 22, 2016

The case for mandating health insurance system

[104] for 2016, the cbo initially estimated that 21 million persons were to be enrolled in the aca exchanges; the cbo has revised that number downward to just 13 million. beyond the aca, federal health policies governing the pre-obamacare health care arrangements, particularly the insurance markets, were profoundly flawed.[8] according to a 2013 survey of registered voters, 62 percent said that “making health care more affordable” was their top priority, while “improving quality” was identified by 19 percent and “expanding coverage” was identified by 14 percent. 2008 and 2010, much more substantive changes were made to the law, one of the most important of which was to begin an open enrollment period for those receiving subsidized health insurance and anyone buying insurance, including those paying full price, as an individual. see 2014 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u. was a widespread feeling that emergency rooms were misused for non-emergency medical care (the misuse was and is undeniable, not unique to massachusetts, and continues; the relation to healthcare insurance or lack of it was less clear and apparently did/does not exist). moffit, phd, is a senior fellow in the center for health policy studies, of the institute for family, community, and opportunity, at the heritage foundation. and without competition, the price of insurance goes up and the quality goes down.[81] congressional budget office, the budget and economic outlook: 2016 to 2026, p.[105] congressional budget office, the budget and economic outlook: 2016 to 2026, p.[37] while both cases centered on hhs’s implementation of the national organ transplant act of 1984, plaintiffs bringing similar cases in the future could also argue that the proposed rule’s reasoning with respect to gender transition treatments supports prohibiting age-based organ transplant policies on the grounds that section 1557 bars age discrimination. january 2016, for the first time in six years and overcoming political and parliamentary obstacles, congress enacted a repeal of the aca’s major provisions. is an expert in health care policy and frequently is asked to help lawmakers design and draft reforms to the health systems.[8] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. that the administration expects health plans and medical providers to subordinate their own professional judgments to those of the hhs office for civil rights is further clarified when hhs states:To the extent a covered entity did not interpret sex discrimination on the basis of gender identity in this way, the covered entity would have to revise its policies and procedures to provide coverage consistent with this rule’s parameters, which might include revising policies to include gender transition-related care. to remedy that (and foreclose any future administration adopting similar policies), congress needs to either repeal section 1557 (on the grounds that it is redundant) or amend it to include rules of construction specifying that the section’s prohibitions on discrimination may not be applied in ways that have the effect of regulating health plan designs or superseding the moral or ethical standards of health care providers or the professional medical judgments of clinicians. the most controversial change was the addition of a provision which requires firms with 11 or more workers that do not provide "fair and reasonable" health coverage to their workers to pay an annual penalty.[48] by june 2011, enrollment was projected to grow to 342,000 people at an annual expense of . for employers with 50 or more ftes, both standards must be met, or 75% of full-time workers must be enrolled in the firm's health plan.[134] the opm, which administers the federal civil service, ruled that members of congress and staff, even though they are no longer enrolled in the federal employees health benefits program (fehbp), would nonetheless get fehbp subsidies for insurance coverage outside of the fehbp. august 20, 2009, president obama said, “there are no plans under health reform to revoke the existing prohibition on using federal taxpayer dollars for abortions. "the effect of insurance on emergency room visits: an analysis of the 2006 massachusetts health reform)" (pdf). among other differences, consistent with ppaca, the out of pocket spending limits and deductibles are higher under similarly priced (after a ppaca tax credit) ppaca-consistent insurance than the superseded massachusetts insurance law. in 2014, the cbo projected that approximately 4 million individuals would face the mandate penalty in 2016 and generate an estimated billion in revenues. for many moderate-income people, particularly those in good health, the high cost-sharing requirements may not seem worth the premiums paid to get them.[69] congressional budget office, the budget and economic outlook: 2016 to 2026, p.[52] president barack obama, “remarks by the president to a joint session of congress on health care,” september 9, 2009, https://www.[103] congressional budget office, private health insurance premiums and federal policy,” p. in 2014, the first year of full implementation of the title i provisions governing health insurance, americans enrolled in the exchanges experienced premium rate shocks. in 908 pages of statutory text, organized in 10 titles, its prescriptions cover a broad range of big topics:The structure and operations of the health insurance market;. the federal centers for medicare and medicaid services approved the state's waiver application on july 26, 2006, allowing the state to begin enrolling 10,500 people from the waitlist for the masshealth essential program, which provides medicaid coverage to long-term unemployed adults below the poverty line.[37] congressional budget office, “an analysis of health insurance premiums under the patient protection and affordable care act,” november 30, 2009, https://www. for the overwhelming majority of americans, the right policy goal is making health care more affordable. such an expansive application would have significant implications for health policy—involving issues separate from the other legal and practical concerns raised by the proposed regulation, such as how it conflicts with conscience rights protections, or provisions of the administrative procedure act, or federal laws governing relations with indian tribes and the operation of the indian health service. timothy jost of washington and lee university and harold pollack of the university of chicago, prominent academic supporters of the aca, nonetheless acknowledge: “the aca undertook from the beginning an ambitious reform agenda, but some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems. law’s health insurance subsidy program, encompassing both premium- and cost-sharing assistance, is mind-numbingly complex and excruciatingly difficult to administer. repealing the aca’s insurance excise tax and replacing it with a simple cap on the value of insurance as tax-free compensation would be a much better policy. for the overwhelming majority of americans, the right policy goal is making health care more affordable. thus asserted that “expectations that gender can only be constructed within two distinct opposite and disconnected forms (masculinity and femininity)” is a form of “sex stereotyping,” constituting impermissible discrimination “on the basis of sex,” hhs proceeds to specify in the proposed rule that “a covered entity shall not,” among other things:Categorically or automatically exclude from coverage, or limit coverage for, all health services related to gender transition; or otherwise deny or limit coverage, or deny a claim, for specific health services related to gender transition if such denial or limitation results in discrimination against a transgender individual. the proposed rule would apply to virtually every private health plan, its adoption would create a broad avenue for legal challenges to plans limiting or excluding coverage for specific items or services. this regard, it is somewhat ironic that the lead plaintiff in the gilead case, southeastern pennsylvania transportation authority, claimed standing to sue in its capacity as the sponsor of an employee health plan, and thus under this proposed regulation could be subject to similar suits brought by its own enrollees—possibly even over the placement of the same hepatitis c drugs on its formulary. 2014, the administration postponed enforcement of the employer mandate for mid-sized employers to provide coverage until 2016. in 2014, the individual mandate forcing americans to buy federally approved health coverage became effective, but the seeming reluctance of the obama administration to enforce it vigorously was soon evident in various exemptions and delays.[37] while both cases centered on hhs’s implementation of the national organ transplant act of 1984, plaintiffs bringing similar cases in the future could also argue that the proposed rule’s reasoning with respect to gender transition treatments supports prohibiting age-based organ transplant policies on the grounds that section 1557 bars age discrimination.[45] for non-group coverage in the exchanges, between 2016 and 2018, the cbo estimates that premiums for the basic “silver” plans (the benchmark plans in the aca exchanges) will grow about 8 percent annually on average; after 2018, they are projected to rise in line with employment-based plans: roughly between 5 percent and 6 percent per annum on average. in the exchanges, as of march 2015, almost 90 percent of persons were enrolled in lower-cost silver or bronze health plans. given the continuing overall rise in premiums post massachusetts 2006 healthcare insurance reform,[35] the major goal of the 2012 amendment was to introduce price controls on health care itself; it is not directly related to healthcare insurance as are the earlier legislative actions. the department of health and human services (hhs) office of inspector general found multiple managerial failures damaging the website launch: “most critical were the absence of clear leadership, which caused delays in decision-making, lack of clarity in project tasks, and the inability of cms [the centers for medicare and medicaid services] to recognize the magnitude of the problems as the project deteriorated. the major federal health care programs not administered by hhs are those operated by the department of defense, the department of veterans affairs, and the federal employees health benefits program administered by the u. law’s health insurance subsidy program, encompassing both premium- and cost-sharing assistance, is mind-numbingly complex and excruciatingly difficult to administer.[91] under the consolidated appropriations act for 2016, the insurance tax collection is suspended for one year: 2017. legal challenge was filed in the superior court of essex county, contesting the fine imposed for a citizen's failure to get health insurance as well as the fine imposed for a failure to provide information on a tax return as to whether that citizen had health insurance.[56] equally troubling, the aca has apparently accelerated the further concentration of market power in health care delivery, increasing corporate control over private medical practice. one supporter, writing in health affairs, describes how that could occur:[a]nother way to achieve section 1557 protection against discrimination is for hhs or courts to categorize certain diseases as “disabilities.” they also envisioned big reductions in employer and employee insurance costs that would have a direct, positive impact on ordinary americans: “the typical family will save 00 per year. the early years of the implementation of the law, approximately 2% of those eligible were determined not to have had access to affordable insurance, and a small number opted for a religious exemption to the mandate., though the employer mandate has been a staple of the progressive health policy agenda for decades, prominent health policy analysts, such as those at the urban institute, have recently expressed reservations about it and have called for its repeal. such entities include a hospital, health clinic, group health plan, health insurance issuer, physician’s practice, community health center, nursing facility, residential or community-based treatment facility, or other similar entity. the surcharge is applied when an employer does not arrange for a pre-tax payroll deduction system for health insurance (a section 125 plan, or a "cafeteria plan"), and has employees who receive care that is paid from the uncompensated care pool, renamed in october 2007 as the health safety net. based on a review of the literature, it appears that the additional insurance premium costs are, on average, about 9 percent.[86] overall, the cbo also reported that in 2015, the federal government spent a total of 6 billion on health programs (for example, medicaid, medicare, and the aca), a 13 percent increase over the 2014 level, outpacing social security spending, which totaled 2 billion. cbo analysts must try to account for a variety of unpredictable market shifts in insurance coverage that could go in any direction.

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Year Six of the Affordable Care Act: Obamacare's Mounting Problems

joseph antos of the american enterprise institute and his colleagues have observed:The fundamental problem with reliance on centralized control over a sector of the economy as complex and vast as health care is that no person or bureaucracy could possess the requisite knowledge to properly set the dials of control to achieve the best balance of cost and quality.. department of health and human services, office of the assistant secretary of planning and evaluation, aspe issue brief, march 3, 2016, p.[19] “nondiscrimination in health programs and activities; proposed rule,” federal register, p.[13] congressional budget office, the budget and economic outlook: 2016 to 2026, january 2016, https://www. aca also requires health plans to meet federal “essential health benefits” requirements, including 10 categories of health benefits as well as all officially recommended preventive services. for a discussion of this special aca insurance program, see moffit and meredith, “multistate health plans: agents for competition or consolidation?[93] many employers will doubtless scale back their health benefit offerings to avoid the tax. for an entity principally engaged in providing or administering health services or health insurance coverage, all of its operations are considered part of the health program or activity, except as specifically set forth otherwise in this part. obama said that his health reform proposal would not add “a dime” to the federal deficit and insisted from the inception of the debate that the final product would drive down the deficits and be a triumph of fiscal responsibility. its face, section 1557 prohibits discriminatory actions that prevent an individual participating in, or receiving public assistance for, federally funded health care coverage for which the individual otherwise qualifies. implementation of healthcare insurance reform began in june 2006, with the appointment of members of the connector board and the naming of jon kingsdale, a tufts health plan official, as executive director of the connector. in 2014, commonwealth care insurance (and commonwealth choice insurance for those not receiving subsidies) has been replaced by insurance compatible with the federal patient protection and affordable care act. as such, it has the potential to trigger costly and widespread disruption in private health insurance markets. thus, hhs states:[w]e have added language to this proposed definition stating that such funds are federal financial assistance when extended to the entity providing the health insurance coverage or services, whether they are paid directly by the federal government to that entity or to the individual for remittance to the entity providing health insurance coverage or services. in 2010, sara rosenbaum, a prominent supporter of the aca, tellingly delinated that larger issue when she wrote, “first, and perhaps most fundamentally, in a remarkable shift whose precedent lies in the watershed civil rights act of 1964, the aca transforms health insurance into a public accommodation.[13] the rule further stipulates that, as “covered entities,” health care providers must also comply with the rule’s provisions with respect to their own employee health plans. with employers, government and individuals all sharing the responsibility of reform, we continue to have the highest insurance rate in the nation. federal officials enforce rules governing insurance rating, co-payments and deductible levels, and allowable profit and administrative expenses.[81] congressional budget office, the budget and economic outlook: 2016 to 2026, p.[8] today, however, the “typical family” pays about 35 percent of their income for health care.” sara rosenbaum, “a ‘broader regulatory scheme’—the constitutionality of health care reform,” the new england journal of medicine, vol.[8] according to a 2013 survey of registered voters, 62 percent said that “making health care more affordable” was their top priority, while “improving quality” was identified by 19 percent and “expanding coverage” was identified by 14 percent. the aca, federal officials are developing and enforcing an enormous body of regulation of the health care sector of the american economy. 2015, the cbo again assumed that the aca would reduce the federal deficit and estimated that repealing major provisions of the law would increase federal budget deficits by 7 billion over the period from 2016–2025. enacted statute, chapter 58 of the acts of 2006, established a system to require individuals, with a few exceptions, to obtain health insurance. 2015, the cbo reported that medicare spending, which has an enormous influence on america’s health care economy, increased about 7 percent, the fastest rate of growth since 2009. any new health reform agenda, congress cannot ignore the major federal health entitlements. the governor announced that "the average uninsured massachusetts resident will be able to purchase health insurance for 5 per month. under the aca, no qualified health plan can have an actuarial value of less than 60 percent, the so-called bronze-level coverage. care plans provided through commonwealth health insurance connector authority in 2014[edit].[44] congressional budget office, private health insurance premiums and federal policy, february 2016, p. in 908 pages of statutory text, organized in 10 titles, its prescriptions cover a broad range of big topics:The structure and operations of the health insurance market;. family foundation researchers, for example, estimate that one in four employers offering health benefits would be affected. based on a review of the literature, it appears that the additional insurance premium costs are, on average, about 9 percent. addition to health plans, hhs also applies this regulation to physicians, hospitals, and other medical providers. for many moderate-income people, particularly those in good health, the high cost-sharing requirements may not seem worth the premiums paid to get them.[90] not surprisingly, congress recently enacted delays in both the health insurance tax and the 2. alternatively, a company meets the standard if it offers to pay at least 33% of the premium cost of an individual health plan. from those who qualify for heavily subsidized premiums and co-payments, the rest of those who purchase individual and small-group insurance have experienced much higher premiums and much higher than expected deductibles, which in turn reflect the built-in costs of aca’s coverage mandates and insurance regulations. in fact, trend lines showed a steady decline in overall health spending growth that long predated the law’s enactment in 2010, and that pre-aca downturn did have a positive impact on consumer spending. because of their lack of health insurance, uninsured massachusetts residents commonly utilize emergency rooms as a source of primary care.[74] congressional budget office, private health insurance premiums and federal policy, p.”[115] more recently, addressing the potential repeal of the law, the cbo flatly acknowledged that the impact on the deficit could go either way: “the uncertainty is sufficiently great that repealing the aca could in fact reduce deficits over the 2016–2025 period—or could increase deficits by a substantially larger margin than the agencies have estimated. made in 1997 to the portion of the insurance market that related to the individual purchase of insurance had failed. enactment of the aca, some overly exuberant administration allies quickly credited the newly minted law with a decline in the growth of health care spending. foster reported that the law’s medicare provider payment cuts would make 15 percent of hospitals and other medicare part a health care providers unprofitable and “jeopardize” seniors’ access to care. these special subsidies are available only to enrollees who choose a silver-level health plan, which means that the plan must pay 70 percent of the average enrollee’s total medical expenses for covered benefits, with the enrollee paying the rest through deductibles and co-payments. insurance rules standardize offerings and eliminate variation of coverage policies among the states, but the price is higher premium costs and an impediment both to innovation in benefit design and to opening up opportunities for individuals, particularly young persons who resist buying insurance, to secure more affordable coverage. the aca, federal officials are developing and enforcing an enormous body of regulation of the health care sector of the american economy. and putatively efficient administrative payment for high-quality medical outcomes is at the heart of the aca’s “delivery reforms. to the contrary, the country has experienced a further concentration of the health insurance markets. enterprise institute analysts say, “given that there is an economic trade-off between wages and benefits, the cadillac tax disproportionately harms lower-income workers with generous health benefit plans. insurers and employee benefit managers, who should be alarmed by the prospect of the federal government turning their private health plans into “public accommodations” or “regulated utilities,” need to recognize that the proposed rule’s interpretation of section 1557 reflects obamacare’s basic, underlying philosophy. the statute also formed a health care quality and cost council to issue quality standards and publicize provider performance.”[115] more recently, addressing the potential repeal of the law, the cbo flatly acknowledged that the impact on the deficit could go either way: “the uncertainty is sufficiently great that repealing the aca could in fact reduce deficits over the 2016–2025 period—or could increase deficits by a substantially larger margin than the agencies have estimated. behavior analysis for children with autism, which a plan might reasonably refuse to cover on the grounds that it is not a medical treatment, but rather an educational methodology that should be funded through existing educational programs for children with learning disabilities, not by health plans. over the period from 2016 to 2025, americans will pay an estimated 2 billion in taxes, including taxes on health insurance plans, drugs, and medical devices that will be passed on to the middle class. this narrowed application is consistent with hhs’ enforcement authority over such health programs and activities, but other federal agencies are encouraged to adopt the standards set forth in this proposed rule in their own enforcement of section 1557” (fn. in 2013, there were 395 insurers operating in the non-group market; in 2015, there were 307; but in 2016, there are only 287..gov/sites/default/files/114th-congress-2015-2016/workingpaper/51065-aca_labor_market_effects_wp.[70] for his part, in 2010, president obama said, “every single good idea to bend the cost curve and start actually reducing health care costs [is] in this bill.[13] the rule further stipulates that, as “covered entities,” health care providers must also comply with the rule’s provisions with respect to their own employee health plans.

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Health Insurance for Small and Large Businesses - State and

next step in this logic chain would be to then apply this new test for discrimination to health plan reimbursement policies as well—subjecting to anti-discrimination scrutiny any plan policy that limits coverage of, or payment for, specific items or services. and putatively efficient administrative payment for high-quality medical outcomes is at the heart of the aca’s “delivery reforms. administration cites the law’s five-year expansion of insurance coverage: 20 million additional enrollees. Affordable Care Act is deeply flawed, incurring increased costs, excessive health care spending and taxation, and managerial failures. this regard, it is somewhat ironic that the lead plaintiff in the gilead case, southeastern pennsylvania transportation authority, claimed standing to sue in its capacity as the sponsor of an employee health plan, and thus under this proposed regulation could be subject to similar suits brought by its own enrollees—possibly even over the placement of the same hepatitis c drugs on its formulary.[122] in 2014, only about half of the medicare “accountable care organizations” (acos), the flagship of the delivery reform project, demonstrated savings.[22] the legislature promptly overrode six of the eight gubernatorial section vetoes, on may 4, 2006, and by mid-june 2006 had overridden the remaining two. cbo’s assessments are based on a required and conventional assumption: the continuity of current law, in this case one that authorizes simultaneously massive increases in revenue and unprecedented cuts in provider payments.[98] 2012 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u.”[ 26] thus, it is not difficult to envision this legal theory being applied to health plans.[44] it should be noted that these blue cross carriers do participate in the federal employees health benefits program. a health program or activity also includes all of the operations of a state medicaid program. still, the researchers explain that health costs continued to go up over the period in question, and their overall findings are “incompatible with claims that health reform has cut medical bankruptcy filings significantly. under the aca, no qualified health plan can have an actuarial value of less than 60 percent, the so-called bronze-level coverage. gps/north star opinion research, national survey of registered voters, june 2–5, 2013, cited in whit ayres, 2016 and beyond: how republicans can elect a president in the new america (alexandria, va: resurgent republic, 2015), p.^ "impact of merging the massachusetts non-group and small group health insurance markets" (pdf). federal officials establish or supervise health insurance exchanges for the purchase of health plans. thus, hhs states:[w]e have added language to this proposed definition stating that such funds are federal financial assistance when extended to the entity providing the health insurance coverage or services, whether they are paid directly by the federal government to that entity or to the individual for remittance to the entity providing health insurance coverage or services. the same time, the act (affordable care today) coalition introduced a bill that expanded masshealth (medicaid and schip) coverage and increased health coverage subsidy programs and required employers to either provide coverage or pay an assessment to the state. federal officials establish or supervise health insurance exchanges for the purchase of health plans.”[5] it then defines “health program or activity” as:[t]he provision or administration of health-related services or health-related insurance coverage and the provision of assistance to individuals in obtaining health-related services or health-related insurance coverage. fundamentally, they are problems of legislative design, particularly in the regulation of health insurance:An overly complex system of excessive insurance subsidies,Health benefit mandates and rating rules that greatly increase health insurance costs, and. broadly, the problems with this proposed rule are symptomatic of what is wrong with obamacare’s entire approach to health care reform.. census data on health care insurance types in massachusetts was released in september 2012, and also illustrates the long-term decrease in esi, and an increase in public, free and subsidized insurance. study conducted by the urban institute and released in december 2010 by the massachusetts division of health care finance and policy stated that as of june 2010, 98. haislmaier is senior research fellow in the center for health policy studies, of the institute for family, community, and opportunity, at the heritage foundation., the employer mandate, which requires firms with 50 or more full-time workers to offer federally approved levels of insurance coverage or pay a tax penalty, is the most significant provision affecting business and employment. in august, that state’s insurance department issued a bulletin telling health insurers that, based on federal guidance and its interpretation of section 1557, coverage for infertility treatments could no longer be limited to enrollees under age 40 (as permitted under the connecticut statute) “and is therefore requiring carriers to remove the age limits on infertility benefits for policies issued or renewed on or after january 1, 2016. surprisingly, for sound philosophical reasons that are deeply rooted in america’s rich political culture of personal liberty, those americans who opposed enactment of the aca have expressed profound aversion to government control of their health care decisions.[53] for a brief survey of the professional literature, see congressional budget office, private health insurance premiums and federal policy, pp.", compared bankruptcy filers from 2007, before reforms were implemented, to those filing in the post-reform 2009 environment to see what role medical costs played.[118] other revenues crucial to the aca’s deficit-reduction potential are its increasingly unpopular taxes such as the cadillac tax, medical device tax, and health insurance tax. reasoning used by the obama administration to arrive at its requirement that health plans cover “gender transition” treatments sets a troubling precedent for future de facto coverage mandates.[35] during the 2009 debate, jonathan gruber, mit professor of economics and an administration adviser, also predicted, “what we know for sure is the bill will lower the cost of buying non-group health insurance. (the state of massachusetts stopped putting out regular information on various types of insurance enrollment altogether between 2011 and 2013; prior to 2011, it released such data quarterly. in their very first report on the impact of the law in 2010, analysts with the cms office of the actuary estimated that in 10 years, national health spending would increase by an estimated 1 billion more than it would have increased if the law had not been enacted.[105] congressional budget office, the budget and economic outlook: 2016 to 2026, p. in 2014, the first year of full implementation of the title i provisions governing health insurance, americans enrolled in the exchanges experienced premium rate shocks. individuals and families would control the flow of health care dollars in the system, directly exercise economic power, and determine the kind of health plans and benefits, medical procedures, and treatments that they want in accordance not only with their medical and economic needs, but also with their ethical, moral, and religious convictions.[19] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. to the contrary, the country has experienced a further concentration of the health insurance markets. in june, the national women’s law center filed administrative complaints with the hhs office for civil rights arguing that the exclusion of dependent pregnancy coverage under the employee health plans of five representative institutions constitutes impermissible discrimination under section 1557., because nearly all medical facilities, physicians, and ancillary health care providers receive at least some federal funding, either by treating patients whose care is paid for with federal funds, or from other sources—such as, “meaningful use” payments for adopting electronic health records, research grants from the national institutes of health, or federal funding of health professional training programs—hhs expects that this rule will also apply to virtually all medical providers.[134] under section 1312 d of the affordable care act, congress voted itself out of its existing insurance coverage and required most members and staff to get coverage in the exchange. constituent elements of health spending are showing an upward surge. million would pay less for any penalty than they would to buy the least expensive insurance available to them. 2012, the blue cross foundation of massachusetts funded and released in april research that showed that the 2006 law and its subsequent amendments – simply in terms of measuring the state-budget effect on the uncompensated care pool and funding subsidized insurance (see background section above) had cost approximately billion in fiscal year 2011 versus approximately billion in fiscal year 2006. for millions of americans, the most costly insurance mandates and regulations affect their coverage.[109] 2015 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u. 2016, the individual mandate tax penalty for a single adult has increased to 5. the coalition began gathering signatures to place their proposal on the ballot in november 2006 if the legislature did not enact comprehensive health care reform, resulting in the collection of over 75,000 signatures on the massact ballot proposal. fact, the aca authorizes federal funding of abortion in its “qualified” health plans, a sharp break from previous law.[citation needed] to try to compensate for these higher limits and deductibles, the commonwealth funded an additional insurance program called connectorcare, by which residents who previously would have qualified for commonwealth care can get very similar benefits for about the same price. both commonwealth care and ppaca-consistent insurance is networked and almost all versions of both insurances offered gym memberships.[58] for 2016, the employer tax penalty for each uncovered worker is from ,160 to ,240. million persons enrolled in the exchanges rather than the expected 11 million; for 2016, the cbo projects 13 million exchange enrollees, a big drop from the agency’s earlier projection of 21 million. 2014, narrower than anticipated networks in health insurance exchange plans and higher than expected deductibles resulted in lower plan premiums, which in turn reduced the cost of the federal insurance subsidies and thus overall projected aca spending. the mandate thus artificially overprices insurance for young people while artificially underpricing insurance for older enrollees. administration’s clear intention to expansively apply the proposed rule sets a course for the federal government to potentially impose numerous benefit mandates on private insurer and employer health plans. 2009, making his case to congress for reform, president obama said:My guiding principle is, and always has been, that consumers do better when there is choice and competition. separate research on premiums and expenditures released by the massachusetts dhcfp in may 2012 found that fully adjusted premiums per member per month (ppmpm) for massachusetts residents covered by comprehensive private insurance policies (approximately two thirds of the state population) increased approximately 9% in both 2009 and 2010 (latest data available) for subscribers in the "merged market", 7% in the midsized group market, and 5.[13] “nondiscrimination in health programs and activities; proposed rule,” federal register, p.

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The Obama Administration's Design for Imposing More Health Care

2016, the individual mandate tax penalty for a single adult has increased to 5.[35] to be clear, the president did not claim a relative slowing of premium growth or a decline from higher than anticipated costs, but rather a decline in family costs resulting from major savings generated by his reforms.. department of health and human services, centers for medicare and medicaid services, office of the actuary, april 22, 2010, https://www.[33] prior to that 2010 change, under the massachusetts law, residents buying healthcare insurance individually could do so at any time, even—theoretically—as being admitted to a hospital or entering an emergency room. lest there be any doubt, in the preamble hhs explicitly states:Thus, for example, an issuer that participates in the marketplace and thereby receives federal financial assistance, and that also offers plans outside the marketplace, will be covered by the proposed regulation for all of its health plans, as well as when it acts as a third party administrator for an employer-sponsored group health plan. for an entity principally engaged in providing or administering health services or health insurance coverage, all of its operations are considered part of the health program or activity, except as specifically set forth otherwise in this part. boston: commonwealth of massachusetts, division of health care finance and policy (dhcfp).. 3762: restoring americans’ healthcare freedom reconciliation act of 2015 as reported by the house committee on the budget october 16, 2015,” cbo cost estimate, october 20, 2015, https://www. for example:In june 2015, the cbo said that the law’s combination of subsidies, taxes, and medicaid expansions would “discourage” work.[98] 2012 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u. first, hhs defines a “covered entity” subject to the regulations as an “entity that operates a health program or activity, any part of which receives federal financial assistance. of all of the variables contributing to the slowdown, claim bradley herring of johns hopkins university and erin trish of the university of southern california, “the most important…appears to be the great recession’s effect on reduced real per capita income and the subsequent effect on reduced health care spending, as about 41% of the recent slowdown can be explained by these reductions in income. for 2016, however, the cbo projects an increased deficit of 4 billion and a return to a fiscally ruinous status quo ante, with annual deficits piling up year after year to reach an accumulated total of .” in essence, the obama administration is asserting that, under the guise of enforcing “non-discrimination,” the hhs office for civil rights has the power to impose coverage mandates on private health plans and to determine what constitutes appropriate medical practice. text of section 1557 references existing statues prohibiting discrimination on the basis of race, color, national origin, sex, age, or disability, and applies them to federally funded health programs, including the aca’s subsidies for coverage purchased through health insurance exchanges.. department of health and human services, centers for medicare and medicaid services, office of the actuary, may, 18, 2012, p.[13] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. broadly, the problems with this proposed rule are symptomatic of what is wrong with obamacare’s entire approach to health care reform. individuals and families would control the flow of health care dollars in the system, directly exercise economic power, and determine the kind of health plans and benefits, medical procedures, and treatments that they want in accordance not only with their medical and economic needs, but also with their ethical, moral, and religious convictions. the department of health and human services (hhs) office of inspector general found multiple managerial failures damaging the website launch: “most critical were the absence of clear leadership, which caused delays in decision-making, lack of clarity in project tasks, and the inability of cms [the centers for medicare and medicaid services] to recognize the magnitude of the problems as the project deteriorated.” although administration officials believed that their delivery reforms—such as “value based purchasing” for hospitals and “pay for performance” for physicians—would be both cost-effective and productive, in 2010, the cbo declined to score them as having any effect on health care spending. a health program or activity also includes all of the operations of a state medicaid program.[58] for 2016, the employer tax penalty for each uncovered worker is from ,160 to ,240. 2014, the administration postponed enforcement of the employer mandate for mid-sized employers to provide coverage until 2016. those 164 million americans have coverage that is issued or administered by one of 181 insurance companies that would be subject to this regulation because those insurers also provide coverage to other individuals under federally subsidized aca exchange plans, medicare advantage plans, or medicaid managed-care contracts.[56] equally troubling, the aca has apparently accelerated the further concentration of market power in health care delivery, increasing corporate control over private medical practice. same legal strategy—based on defining medical conditions as disabilities, and augmented by the proposed rule’s precedent-setting reasoning for finding refusals to cover gender transition treatments discriminatory—could also be applied to health plan coverage of other controversial treatments.% of the population) were covered by individually purchased insurance but the number had dropped to under 50,000 by the time of the reform debate."chapter 58 of the acts of 2006, an act providing access to affordable, quality accountable health care".[134] the opm, which administers the federal civil service, ruled that members of congress and staff, even though they are no longer enrolled in the federal employees health benefits program (fehbp), would nonetheless get fehbp subsidies for insurance coverage outside of the fehbp., the federal government’s website for enrollment in the health insurance exchanges. with medicare, a reform agenda would build on the already existing—and highly popular—defined-contribution financing systems for comprehensive health plans in medicare advantage and the broad range of drug coverage in medicare part d. in their 2015 report, the medicare trustees largely echoed the actuary’s concerns about the impact of the payment reductions and seniors’ access to care: “by 2040, simulations suggest that approximately half of hospitals, 70 percent of skilled nursing facilities, and 90 percent of home health agencies would have negative total facility margins, raising the possibility of access and quality of care issues for medicare beneficiaries.[103] congressional budget office, private health insurance premiums and federal policy,” p. Affordable Care Act is deeply flawed, incurring increased costs, excessive health care spending and taxation, and managerial failures. september 8, 2015, the department of health and human services’ (hhs) office for civil rights published in the federal register a proposed regulation entitled “nondiscrimination in health programs and activities,” interpreting and implementing section 1557 of the affordable care act (aca or obamacare). for example:Reason #1: despite the president’s repeated promises, rising insurance costs continue to burden businesses and families.[84] the aca’s health insurance subsidies will register an average annual growth rate of 9. august 11, 2009, during the initial stages of the congressional debate, president obama said, “my belief is…that [health reform] should not burden people who make 0,000 a year or less. in addition, federal laws governing private health insurance policies and employer health plans also ensure that individuals cannot be denied private coverage for which they otherwise qualify, including on the basis of health status or genetic information. the open enrollment period of the insurance marketplace, during which citizens may re-enroll or purchase, lasted from 1 october 2013 to 31 march 2014, but those who did not re-enroll by december 15, were to have no insurance coverage in january 2014 (unless they were among the 100,000 moved to medicaid). health insurers with multiple lines of business, including administering self-insured plans, that would mean deciding which market segments—subsidized or unsubsidized—they will serve, and restructuring their businesses accordingly.[113] congressional budget office, the budget and economic outlook: 2016 to 2026, p.[88] the administration’s allies in congress and elsewhere may judge this a laudable expansion of government’s role in health care, but it does nothing to bend the notorious “cost curve” downward. [and] improvements in several determinants of overall health, including physical health, mental health, functional limitations, joint disorders, body mass index, and moderate physical activity. simultaneously “bending the cost curve” downward and increasing insurance enrollment and government subsidies would have been a neat trick[79] for a law that created new federal entitlements and thus became a powerful engine of massive future federal spending. however, this proposed rule would apply only to health programs and activities any part of which receives federal financial assistance from hhs.’ health care worries are real, and their concerns are practical. for group coverage, the cbo projects that premium growth will accelerate over the period from 2016 to 2025, increasing by “nearly” 60 percent..gov/sites/default/files/114th-congress-2015-2016/reports/50252-effects_of_aca_repeal. the very inception of the debate, president obama repeatedly insisted that american families would experience an annual reduction of ,500 in their health costs. and without competition, the price of insurance goes up and the quality goes down. movement to reform massachusetts healthcare insurance regulations and market between 2004 and 2006 was driven by multiple issues, not all of which were clearly an issue or directly related to then and now most critical issues of rising costs:A six-year-old federal-government waiver as to how massachusetts administered its medicaid program was expiring., while the obama administration had to resort to devising a contorted reinterpretation of the concept of sex discrimination to justify mandating coverage for “gender transition” treatments, the concept of “disability” (another category of prohibited discrimination under section 1557) is already sufficiently broad that the federal government could easily use it to justify imposing similar coverage and treatment mandates in other circumstances. the number of persons under the age of 65 with private insurance has shrunk from 77 percent in 1984 to 62 percent in 2013, and this decline, particularly in the 1990s, was attributable to premium increases. manner in which this proposed rule would regulate health plans and providers is most clearly illustrated by the administration’s inclusion in the rule of provisions that explicitly apply to one particular psychological condition.[65] congressional budget office, the budget and economic outlook: 2016 to 2026, p. president’s assertions that his policy would redirect the health cost trajectory downward were rooted in his presidential campaign advice. the first half of 2007 to the first half of 2009, spending from the health safety net fund dropped 38%–40%, as more people became insured. that the administration expects health plans and medical providers to subordinate their own professional judgments to those of the hhs office for civil rights is further clarified when hhs states:To the extent a covered entity did not interpret sex discrimination on the basis of gender identity in this way, the covered entity would have to revise its policies and procedures to provide coverage consistent with this rule’s parameters, which might include revising policies to include gender transition-related care. in august, that state’s insurance department issued a bulletin telling health insurers that, based on federal guidance and its interpretation of section 1557, coverage for infertility treatments could no longer be limited to enrollees under age 40 (as permitted under the connecticut statute) “and is therefore requiring carriers to remove the age limits on infertility benefits for policies issued or renewed on or after january 1, 2016. on july 1, masshealth began covering dental care and other benefits, and began enrolling children between 200% and 300% of the poverty level.

Health Reform and Coverage Changes Among Native Americans

.gov/sites/default/files/114th-congress-2015-2016/reports/50252-effects_of_aca_repeal.[139] the top goal should be to empower individuals and families as the key decision-makers in the health care economy. next step in this logic chain would be to then apply this new test for discrimination to health plan reimbursement policies as well—subjecting to anti-discrimination scrutiny any plan policy that limits coverage of, or payment for, specific items or services.^ a b "chapter 58 of the acts of 2006, an act providing access to affordable, quality accountable health care". the major federal health care programs not administered by hhs are those operated by the department of defense, the department of veterans affairs, and the federal employees health benefits program administered by the u.^ "research on providing health coverage for the uninsured in massachusetts". aca has also effected a massive erosion of the states’ traditional authority over health insurance regulation. kaiser researchers estimated that the economic decline was responsible for 77 percent of the decrease in health spending growth during that period. repealing the aca’s insurance excise tax and replacing it with a simple cap on the value of insurance as tax-free compensation would be a much better policy. both trend lines mirror—from different baselines—the approximately 400,000 massachusetts residents added to the rolls of the insured in 2006/2007 via an expansion in medicaid eligibility rules and the subsidization of the commonwealth care insurance program.[35] to be clear, the president did not claim a relative slowing of premium growth or a decline from higher than anticipated costs, but rather a decline in family costs resulting from major savings generated by his reforms. text of section 1557 references existing statues prohibiting discrimination on the basis of race, color, national origin, sex, age, or disability, and applies them to federally funded health programs, including the aca’s subsidies for coverage purchased through health insurance exchanges. is a curious paradox that the aca has generated monumental growth in high-deductible health plans, the very type of coverage that progressives have long found unpalatable and that are sometimes denounced as “junk” insurance. since the amendments passed, courts have more broadly interpreted “disability,” although they continue to assess each case individually. see 2014 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u. “although health care spending grew more slowly in the past several years than it has historically,” the cbo reports, “over the coming decade, per-enrollee spending in federal health programs will grow more rapidly than it has in recent years. unfortunately, in 34 states, 75 percent of the insurance market is controlled by five or fewer companies.[122] in 2014, only about half of the medicare “accountable care organizations” (acos), the flagship of the delivery reform project, demonstrated savings.[120] the controversial board has been defunded for 2016 under the consolidated appropriations act for 2016.”[72] they claimed that, among other things, the embryonic obama health plan could achieve extraordinary savings, amounting to hundreds of billions of dollars annually, from federal “investments” in information technology and reduced overhead in health insurance, improved disease management, care coordination, clinical effectiveness, and “pay for performance” and related “delivery reforms. the plaintiffs asserted that gilead discriminated against the disabled because it charged more for its drugs to people in the united states than it charged abroad, charged more for individuals who are not part of health programs or plans that received discounts, caused health plans and programs to refuse access to its drugs, and denied access itself because of “excessive and discriminatory pricing practices, contracts and policies. the sheer magnitude of the aca’s insurance subsidies, it is odd that exchange enrollment is falling well short of official expectations. 2015, at the county level where health insurance reflects local pricing, consumers in one-third of the nation’s 3,134 counties bought coverage in exchange markets that were dominated by a monopoly (only one insurer) or duopoly (only two insurers).[45] in 2016, in employment-based insurance plans, the average premium is estimated to be ,400 for single coverage and about ,500 for family coverage. september 8, 2015, the department of health and human services’ (hhs) office for civil rights published in the federal register a proposed regulation entitled “nondiscrimination in health programs and activities,” interpreting and implementing section 1557 of the affordable care act (aca or obamacare). practical effect of adopting the proposed rule would be to open a pandora’s box of potential new federal health care benefit mandates, with costly consequences for private insurers, employer health plans—and ultimately, their enrollees who bear those costs in the form of either higher premiums or lower cash compensation..gov/sites/default/files/114th-congress-2015-2016/reports/51130-health_insurance_premiums_onecol. november 2004, political leaders began advocating major reforms of the massachusetts health care insurance system to expand coverage. 2015, at the county level where health insurance reflects local pricing, consumers in one-third of the nation’s 3,134 counties bought coverage in exchange markets that were dominated by a monopoly (only one insurer) or duopoly (only two insurers). that some state legislatures have already been persuaded to mandate that health insurers cover the foregoing items and services, it is not hard to imagine the hhs office for civil rights, or federal judges, applying the proposed rule to achieve the same results at the federal level. for a discussion of this special aca insurance program, see moffit and meredith, “multistate health plans: agents for competition or consolidation?^ a b c report from massachusetts secretary of health and human services, timothy murphy, to the massachusetts general court, "chapter 58 implementation update" (june 12, 2006).[9] the temporary slowdown in health spending, which started in the early 2000s, is over, and businesses, individuals, and families are once again threatened with higher health care costs. taxes that fed the state's "free care pool",[6] which covered uninsured emergency room visits as well as uninsured hospital admissions (as well as funding community health centers), consistently underfunded the pool and had to be raised almost annually (with differences made up by appropriations from general revenue). foster reported that the law’s medicare provider payment cuts would make 15 percent of hospitals and other medicare part a health care providers unprofitable and “jeopardize” seniors’ access to care. in fact, trend lines showed a steady decline in overall health spending growth that long predated the law’s enactment in 2010, and that pre-aca downturn did have a positive impact on consumer spending. the number of persons under the age of 65 with private insurance has shrunk from 77 percent in 1984 to 62 percent in 2013, and this decline, particularly in the 1990s, was attributable to premium increases. in the full-price commonwealth choice plans, offered through the commonwealth health insurance connector, fluctuates between 15,000-20,000 according to the state. the cbo projects that it will remain at that level in 2016 and fall again to 62. january 2016, for the first time in six years and overcoming political and parliamentary obstacles, congress enacted a repeal of the aca’s major provisions.[35] during the 2009 debate, jonathan gruber, mit professor of economics and an administration adviser, also predicted, “what we know for sure is the bill will lower the cost of buying non-group health insurance. specifically, under this new rule, refusals by health plans to cover “gender transition” (commonly known as “sex change”) treatments may be determined by hhs to constitute impermissible discrimination under federal civil rights laws."chapter 205 of the acts of 2007, an act further regulating health care access".. house of representatives, “re: spending for means-tested programs in cbo’s baseline, 2016–2026,” february 16, 2016, p. fall 2005, the house and senate each passed health care insurance reform bills. lest there be any doubt, in the preamble hhs explicitly states:Thus, for example, an issuer that participates in the marketplace and thereby receives federal financial assistance, and that also offers plans outside the marketplace, will be covered by the proposed regulation for all of its health plans, as well as when it acts as a third party administrator for an employer-sponsored group health plan. of other controversial treatments that, under the proposed rule, could soon become the focus of federal lawsuits or regulations can already be found among some existing state health insurance benefit mandates, such as those requiring coverage for:Off-label use of a prescription drug, which a plan might not pay for on the grounds that the treatment is unproven or experimental;., interpreting section 1557 of the aca, the administration issued a sweeping proposed rule requiring that all health plans must provide medical benefits or procedures in accordance with the new “gender” anti-discrimination standards of the hhs office of civil rights. division of health care finance and policy defined by regulation what contribution level meets the "fair and reasonable" test in the statute. civil rights statutes already guarantee all americans access to any federal health care program or subsidy for which they otherwise qualify. this proposed rule, the administration not only asserts the power to determine what constitutes appropriate medical treatment; it also defines the scope of the rule so broadly that it will apply to virtually all current health plans and medical providers.^ "analysis of individual health coverage in massachusetts before and after the july 1, 2007 merger of the small group and nongroup health insurance markets" (pdf). as the cbo has noted, “operating in a more competitive market gives insurers a stronger incentive to limit the premiums that they charge and to constrain their administrative costs and profits—but in many parts of the united states, insurance markets are not very competitive. same legal strategy—based on defining medical conditions as disabilities, and augmented by the proposed rule’s precedent-setting reasoning for finding refusals to cover gender transition treatments discriminatory—could also be applied to health plan coverage of other controversial treatments. the normal age variation in health costs between older and younger persons is about five or six to one, not three to one. for 2016, exchange enrollments have already fallen below the cbo’s initial projections, as well as the projections of the administration, the urban institute, and the rand corporation., because nearly all medical facilities, physicians, and ancillary health care providers receive at least some federal funding, either by treating patients whose care is paid for with federal funds, or from other sources—such as, “meaningful use” payments for adopting electronic health records, research grants from the national institutes of health, or federal funding of health professional training programs—hhs expects that this rule will also apply to virtually all medical providers. for 2016, however, the cbo projects an increased deficit of 4 billion and a return to a fiscally ruinous status quo ante, with annual deficits piling up year after year to reach an accumulated total of . following enactment of mandatory insurance showed total emergency visits and spending continued to increase, and low-severity emergency visits decreased less than 2%; researchers concluded, "to the extent that policymakers expected a substantial decrease in overall and low-severity ed visits, this study does not support those expectations., hhs makes clear its intention to apply this regulation to all of a health insurer’s business if any of the insurer’s customers receive a federal coverage subsidy., interpreting section 1557 of the aca, the administration issued a sweeping proposed rule requiring that all health plans must provide medical benefits or procedures in accordance with the new “gender” anti-discrimination standards of the hhs office of civil rights. the most compelling reason for the slowdown in the growth of health care spending had little or nothing to do with the aca.

Patient Protection and Affordable Care Act - Wikipedia

Effects of the Affordable Care Act on Part-Time Employment: Early

[45] for non-group coverage in the exchanges, between 2016 and 2018, the cbo estimates that premiums for the basic “silver” plans (the benchmark plans in the aca exchanges) will grow about 8 percent annually on average; after 2018, they are projected to rise in line with employment-based plans: roughly between 5 percent and 6 percent per annum on average. addition to health plans, hhs also applies this regulation to physicians, hospitals, and other medical providers.[36] in 2006, the division of health care finance and policy issued regulations defining "fair and reasonable" for the fair share assessment. for many persons, the trade-off is perfectly reasonable, but the law imposes costly comprehensive benefit requirements and insurance rules, so for many middle-income persons, given that there is no legal alternative, the choice of insurance is constrained.[109] 2015 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds, transmitted to the speaker of the u. in the exchanges, as of march 2015, almost 90 percent of persons were enrolled in lower-cost silver or bronze health plans. enterprise institute analysts say, “given that there is an economic trade-off between wages and benefits, the cadillac tax disproportionately harms lower-income workers with generous health benefit plans. another analysis, researchers at the kaiser family foundation reported that the average annual growth in health care spending was 8.” thus, section 1557 could be turned into a tool for detailed federal regulation of prescription drug formulary designs in employer and insurer health plans.[91] under the consolidated appropriations act for 2016, the insurance tax collection is suspended for one year: 2017.[13] congressional budget office, the budget and economic outlook: 2016 to 2026, january 2016, https://www. administration cites the law’s five-year expansion of insurance coverage: 20 million additional enrollees. haislmaier is senior research fellow in the center for health policy studies, of the institute for family, community, and opportunity, at the heritage foundation. with medicare, a reform agenda would build on the already existing—and highly popular—defined-contribution financing systems for comprehensive health plans in medicare advantage and the broad range of drug coverage in medicare part d.[128] in the case of the special “multi-state health plans” administered by the opm, the law requires the federal government, beginning in 2014, to contract with at least two national health plans, one of which must offer abortion coverage in the aca exchanges. august 11, 2009, during the initial stages of the congressional debate, president obama said, “my belief is…that [health reform] should not burden people who make 0,000 a year or less. of other controversial treatments that, under the proposed rule, could soon become the focus of federal lawsuits or regulations can already be found among some existing state health insurance benefit mandates, such as those requiring coverage for:Off-label use of a prescription drug, which a plan might not pay for on the grounds that the treatment is unproven or experimental;. 2015, the cbo again assumed that the aca would reduce the federal deficit and estimated that repealing major provisions of the law would increase federal budget deficits by 7 billion over the period from 2016–2025.[21] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. hhs states, “section 1557 applies to all health programs and activities, any part of which receives federal financial assistance from any federal department. unfortunately, in 34 states, 75 percent of the insurance market is controlled by five or fewer companies. title i, federal officials define the content of health insurance coverage, including required medical treatments, procedures, and preventive health care services. january 2016, the cbo again projected a decline in labor force participation and a negative impact on economic growth:Cbo anticipates that several developments in federal fiscal policy under current law will affect the economy through their impact on the labor market. moffit is a senior fellow in the heritage foundation's center for health policy studies. even so, hhs claims that its proposed rule “does not require plans to cover any particular benefit or service,”[19] and includes in the rule a subsequent paragraph stating:Nothing in this section is intended to determine, or restrict a covered entity from determining, whether a particular health service is medically necessary or otherwise meets applicable coverage requirements in any individual case. reasoning used by the obama administration to arrive at its requirement that health plans cover “gender transition” treatments sets a troubling precedent for future de facto coverage mandates.[126] congressional budget office, the budget and economic outlook: 2016 to 2026, p. constituent elements of health spending are showing an upward surge. so-called cadillac tax—the 40 percent excise tax on “high value” health plans (in excess of ,200 for single coverage and ,500 for family coverage)—is also in effect a tax on the middle class. cbo’s assessments are based on a required and conventional assumption: the continuity of current law, in this case one that authorizes simultaneously massive increases in revenue and unprecedented cuts in provider payments. the very inception of the debate, president obama repeatedly insisted that american families would experience an annual reduction of ,500 in their health costs..gov/sites/default/files/114th-congress-2015-2016/reports/51180-2016outlooktestimony_hbc. its many effects, the law established an independent public authority, the commonwealth health insurance connector authority, also known as the massachusetts health connector. over the period from 2013 to 2015, medicaid spending increased by 32 percent, according to the cbo; it will increase by 9 percent in 2016, and only then will medicaid spending growth begin to taper off. in 2009, following the advice of professor jonathan gruber of mit, a prominent health policy specialist, president obama reversed himself. also the law’s government health insurance exchanges, heavily regulated and federally supervised health insurance mechanisms that are markedly different in goals and functions from market-based exchanges. employers—even large employers that were self-insured—were increasingly dropping health insurance as an employee benefit and/or restricting it to "full-time employees such that the "take up rate" of healthcare insurance by employees was dropping. the normal age variation in health costs between older and younger persons is about five or six to one, not three to one.” furthermore, it is also clear from the first paragraph that hhs considers its office for civil rights’ opinion of what is “medically necessary” to be superior to the opinions of health plans.[31] in 2017, the law provides for a waiver from federal rules for state experimentation if, and only if, the secretary of health and human services should grant such a waiver. for many years, there has been a downward trend in young americans enrolling in health insurance coverage. healthcare insurance reform law was enacted as chapter 58 of the acts of 2006 of the massachusetts general court; its long form title is an act providing access to affordable, quality, accountable health care. study published in the american journal of medicine, "medical bankruptcy in massachusetts: has health reform made a difference? approximately 100,000 massachusetts residents who received free or highly subsidized commonwealth care insurance, will be moved to medicaid.[14] it was predicted that implementation of the 2006 massachusetts healthcare insurance reform law would result in almost complete elimination of the need for this fund. with certain statutory or administrative exceptions, all americans are legally required to provide or enroll in federally approved insurance coverage or pay a tax penalty for refusing to provide such coverage as an employer or to enroll in such coverage as an individual. however, in the proposed regulation the obama administration further expansively interprets that already broad, statutory text to also apply those prohibitions to the benefits covered by health insurance plans, the treatments provided by medical professionals, and the health insurance coverage of tens of millions of americans enrolled in private, unsubsidized plans.[74] congressional budget office, private health insurance premiums and federal policy, p. a business that fails that test may still be deemed to offer a "fair and reasonable" contribution if the company offers to pay at least 33 percent of an individual’s health insurance premium.[31] in 2017, the law provides for a waiver from federal rules for state experimentation if, and only if, the secretary of health and human services should grant such a waiver.” the final rule should define “benefit design” as including, but not limited to, the following specific elements: prescription drug formularies; health care provider networks (including access to specialists and pharmacy access); wellness programs; tiered coverage and cost-sharing structures for drug formularies and provider networks; cost-sharing charges (including co-payments, co-insurance, deductibles, and other charges enrollees pay for health care items and services); utilization management; quantitative treatment limits; and non-quantitative treatment limits including prior authorization and step therapy.[30] residents must indicate on their tax forms if they had insurance on december 31 of that tax year, had a waiver for religious reasons, or had a waiver from the connector.[21] “nondiscrimination in health programs and activities; proposed rule,” federal register, p.. house of representatives, “re: spending for means-tested programs in cbo’s baseline, 2016–2026,” february 16, 2016, p. aca has also effected a massive erosion of the states’ traditional authority over health insurance regulation. gps/north star opinion research, national survey of registered voters, june 2–5, 2013, cited in whit ayres, 2016 and beyond: how republicans can elect a president in the new america (alexandria, va: resurgent republic, 2015), p. so-called cadillac tax—the 40 percent excise tax on “high value” health plans (in excess of ,200 for single coverage and ,500 for family coverage)—is also in effect a tax on the middle class.[66] congressional budget office, budgetary and economic effects of repealing the affordable care act, june 2015, https://www. the aca, the trends indicate that public spending will account for a progressively larger share of the health care economy than will private spending. based on the combination of the increased health safety net tax, general revenue (state income and sales taxes were increased 20%) and smaller additional taxes, the cost of the reform reached about 2% of the state's annual budget in fiscal year 2013, which ended june 30, 2013, up from 1. federal departments are mostly responsible for the issuance of aca regulations: the department of health and human services, the department of labor, and the department of the treasury, particularly the internal revenue service (irs)., “improving health and health care: an agenda for reform,” p.

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Paul Ryan unveils plan to set fire to the American health care system

for example, for private insurance premiums in all markets, premium growth averaged 4. the most compelling reason for the slowdown in the growth of health care spending had little or nothing to do with the aca. over the period from 2016 to 2025, americans will pay an estimated 2 billion in taxes, including taxes on health insurance plans, drugs, and medical devices that will be passed on to the middle class. at the forum, the foundation issued a series of reports on reform options, all of which included an individual mandate.[90] not surprisingly, congress recently enacted delays in both the health insurance tax and the 2. in their very first report on the impact of the law in 2010, analysts with the cms office of the actuary estimated that in 10 years, national health spending would increase by an estimated 1 billion more than it would have increased if the law had not been enacted. in their 2015 report, the medicare trustees largely echoed the actuary’s concerns about the impact of the payment reductions and seniors’ access to care: “by 2040, simulations suggest that approximately half of hospitals, 70 percent of skilled nursing facilities, and 90 percent of home health agencies would have negative total facility margins, raising the possibility of access and quality of care issues for medicare beneficiaries., vicky, masshealth advocacy guide, massachusetts law reform institute (mlri) and massachusetts continuing legal education, inc. in 2009, following the advice of professor jonathan gruber of mit, a prominent health policy specialist, president obama reversed himself. consequently, the ultimate solution lies in repealing the aca and replacing it with a more reasonable set of health policy reforms—specifically, reforms that do not start from the premise that private heath plans and medical providers should be commandeered by congress and converted into off-budget extensions of federal programs. indeed, because this process started with what could be called a “hard case”—meaning one for which the administration had to creatively and laboriously extrapolate its desired conclusion from the underlying statute—should hhs establish a precedent on such tenuous grounds, it would become much easier to subsequently achieve similar results in other areas..gov/sites/default/files/114th-congress-2015-2016/workingpaper/51065-aca_labor_market_effects_wp.[37] for the vast majority of americans still enrolled in the huge employment-based health insurance markets, the office of the actuary at the centers for medicare and medicaid services reported in april 2010 that the health law’s new taxes on health insurance, drugs, and medical devices would also translate into higher group insurance premiums.[30] sara rosenbaum, a prominent legal expert at george washington university, says as much: “the law fundamentally transforms health insurance from a product designed to preserve profitability in the face of rampant adverse selection to a regulated industry whose long-term strength and stability are essential to the public interest and that, in its restructured form, will therefore take on certain characteristics of a public utility.[87] congressional budget office, the budget and economic outlook: 2016 to 2026, pp.[99] congressional budget office, “payments of penalties for being uninsured under the affordable care act: 2014 update,” june 2014, table 1, “estimated distribution of individual mandate penalties under the affordable care act, calendar year 2016,” https://www. the defendant was a pharmaceutical company, not a health plan, and while the judge dismissed the case on other grounds—including that federal patent law grants pricing freedom to patent holders—the plaintiffs’ claims in this case offer a flavor of what insurers and benefit managers can expect under the proposed rule. illustrated in the state report referenced in the previous sentence, the price of insurance that covered about 600,000 people in the small group market (about 10% of the population) was rising faster than the prices for the vast majority of the non-senior-citizen population, most of which were – and still are – covered by self-insured group insurance from large employers (self-insured plans are not subject to state regulation). more than half of the law’s nonprofit co-op health plans, heavily financed with taxpayer-backed loans and designed to enhance competition in the exchanges, have collapsed.”[46] she went on to note that one effect is to turn health insurance into “a regulated industry…that, in its restructured form, will therefore take on certain characteristics of a public utility. insurance rules standardize offerings and eliminate variation of coverage policies among the states, but the price is higher premium costs and an impediment both to innovation in benefit design and to opening up opportunities for individuals, particularly young persons who resist buying insurance, to secure more affordable coverage.[59] a 2014 study found that the reform was associated with "significant reductions in all-cause mortality and deaths from causes amenable to health care.[46] according to the dhcfp in a report dated september 2011, "total health safety net (hsn) payments increased by 7% in the first six months of health safety net fiscal year 2011 (hsn11) compared to the same period in the prior year[,] while demand increased by 10%. the regulations provide that companies with 11 or more full-time equivalent employees will meet the “fair and reasonable” test if at least 25 percent of those employees are enrolled in that firm’s health plan and the company is making a contribution toward it. plans are to be offered by the following providers: ambetter from celticare, blue cross blue shield of massachusetts (which did not participate in the prior massachusetts health care insurance program), boston medical center healthnet, fallon community health plan, harvard pilgrim health care, health new england, minuteman health, neighborhood health plan (a new plan following the co-op model introduced with ppaca), network health, and tufts health plan.^ "massachusetts health reform spending, 2006–2011: an update on the "budget buster" myth" (pdf). obama administration’s design for imposing more health care mandates.[45] in 2016, in employment-based insurance plans, the average premium is estimated to be ,400 for single coverage and about ,500 for family coverage.[27] during the presidential campaign of 2008, senator obama said that the individual mandate to buy federally approved insurance was unfair and unenforceable. if a resident does not have coverage and does not have a waiver, the department of revenue will enforce the insurance requirement by imposing a penalty. june 2011, a boston globe review concluded that the healthcare overhaul "has, after five years, worked as well as or better than expected.[8] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. in those cases, attorneys for the parents of children with cystic fibrosis convinced federal judges to order that the children be added to the adult lung transplant waiting list (for patients age twelve and older), instead of remaining on the pediatric transplant waiting list—raising a number of concerns among medical ethicist and clinicians.[86] overall, the cbo also reported that in 2015, the federal government spent a total of 6 billion on health programs (for example, medicaid, medicare, and the aca), a 13 percent increase over the 2014 level, outpacing social security spending, which totaled 2 billion. from those who qualify for heavily subsidized premiums and co-payments, the rest of those who purchase individual and small-group insurance have experienced much higher premiums and much higher than expected deductibles, which in turn reflect the built-in costs of aca’s coverage mandates and insurance regulations."[53] a study by the fiscally conservative beacon hill institute was of the view that the reform was "responsible for a dramatic increase in health care spending," however. obama administration’s design for imposing more health care mandates. the implementation of ppaca in 2014, those citizens acquiring insurance through currently available massachusetts health connector plans, will need to re-enroll or select a new plan, given the new guidelines stipulated by ppaca.[27] in 2016, based on official estimates, approximately 90 percent of an estimated 30 million uninsured would not be forced to pay the penalty because of multiplying exemptions. administration’s clear intention to expansively apply the proposed rule sets a course for the federal government to potentially impose numerous benefit mandates on private insurer and employer health plans. relatively few massachusetts residents used the connector to buy full-priced insurance. congressional budget office, private health insurance premiums and federal policy, p. hhs states, “section 1557 applies to all health programs and activities, any part of which receives federal financial assistance from any federal department. the law specifies, for example, that reimbursement for doctors and hospitals is to secure “quality” care or “value” in their transactions with patients, even though there is often profound disagreement among medical professionals on what, in any given case, quality or value may mean in a clinical context in the treatment of specific diseases or medical conditions. in addition, federal laws governing private health insurance policies and employer health plans also ensure that individuals cannot be denied private coverage for which they otherwise qualify, including on the basis of health status or genetic information. such an expansive application would have significant implications for health policy—involving issues separate from the other legal and practical concerns raised by the proposed regulation, such as how it conflicts with conscience rights protections, or provisions of the administrative procedure act, or federal laws governing relations with indian tribes and the operation of the indian health service. is a curious paradox that the aca has generated monumental growth in high-deductible health plans, the very type of coverage that progressives have long found unpalatable and that are sometimes denounced as “junk” insurance.[104] for 2016, the cbo initially estimated that 21 million persons were to be enrolled in the aca exchanges; the cbo has revised that number downward to just 13 million.[27] “nondiscrimination in health programs and activities; proposed rule,” federal register, p. with more than ten full-time equivalent employees (ftes) must provide a "fair and reasonable contribution" to the premium of health insurance for employees.. 3762: restoring americans’ healthcare freedom reconciliation act of 2015 as reported by the house committee on the budget october 16, 2015,” cbo cost estimate, october 20, 2015, https://www. the aca, the trends indicate that public spending will account for a progressively larger share of the health care economy than will private spending. statute expanded masshealth (medicaid and schip) coverage for children of low income parents and restores masshealth benefits like dental care and eyeglasses., hhs makes clear its intention to apply this regulation to all of a health insurer’s business if any of the insurer’s customers receive a federal coverage subsidy. a much larger portion of the pool was used for non-ed hospital care for the uninsured and for other care at community health centers. fact, heritage foundation research has confirmed that the aca has not increased health plan competition. the mandate thus artificially overprices insurance for young people while artificially underpricing insurance for older enrollees. a plan’s “benefits” to encompass not only specific items or services, but also any limits on coverage or payment for specific items or services, would make numerous design features of public and private health plans subject to legal challenges under section 1557.[82] on a per capita basis, based on cms data, total spending on health insurance will rise from ,786 in 2016 to ,681 in 2024. such entities include a hospital, health clinic, group health plan, health insurance issuer, physician’s practice, community health center, nursing facility, residential or community-based treatment facility, or other similar entity. comparison, commonwealth care insurance had either zero or 0 deductibles (depending on which of three types of commonwealth care insurance it was) and zero or very low co-pays as compared to the ppaca-consistent insurance (not illustrated in the table).[69] congressional budget office, the budget and economic outlook: 2016 to 2026, p.

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in 2006, an mit economics professor jonathan gruber predicted that the amount of money in the "free care pool" would be sufficient to pay for reform legislation without requiring additional funding or taxes. under the protecting americans from tax hikes act of 2015, the medical device tax is delayed for 2016 and 2017. under the protecting americans from tax hikes act of 2015, the medical device tax is delayed for 2016 and 2017.[125] keith hall, director, congressional budget office, “the budget and economic outlook: 2016 to 2026,” testimony before the committee on the budget, u. behavior analysis for children with autism, which a plan might reasonably refuse to cover on the grounds that it is not a medical treatment, but rather an educational methodology that should be funded through existing educational programs for children with learning disabilities, not by health plans. practical effect of adopting the proposed rule would be to open a pandora’s box of potential new federal health care benefit mandates, with costly consequences for private insurers, employer health plans—and ultimately, their enrollees who bear those costs in the form of either higher premiums or lower cash compensation. initial bids received by the connector showed a likely cost for the minimum insurance plan of about 0 per month.[44] congressional budget office, private health insurance premiums and federal policy, february 2016, p. this proposed rule, the administration not only asserts the power to determine what constitutes appropriate medical treatment; it also defines the scope of the rule so broadly that it will apply to virtually all current health plans and medical providers.[42] healthpocket, a national firm comparing rates and benefits, reports that insurers in 45 states have requested an average premium rate increase of 12 percent.[88] the administration’s allies in congress and elsewhere may judge this a laudable expansion of government’s role in health care, but it does nothing to bend the notorious “cost curve” downward.[94] the unlimited tax treatment of employer-based health insurance, as the late milton friedman and many other prominent economists have long argued, contributes to excessive health care costs.[52] president barack obama, “remarks by the president to a joint session of congress on health care,” september 9, 2009, https://www. with medicaid, congress could likewise create a strong “premium support” or defined-contribution system that would mainstream low-income persons into the private health insurance markets. consequently, the ultimate solution lies in repealing the aca and replacing it with a more reasonable set of health policy reforms—specifically, reforms that do not start from the premise that private heath plans and medical providers should be commandeered by congress and converted into off-budget extensions of federal programs.[8] today, however, the “typical family” pays about 35 percent of their income for health care. moffit is a senior fellow in the heritage foundation's center for health policy studies. law’s most publicized operational problems surfaced with the disastrous october 2013 rollout of healthcare..1 health care plans provided through commonwealth health insurance connector authority in 2014. for group coverage, the cbo projects that premium growth will accelerate over the period from 2016 to 2025, increasing by “nearly” 60 percent.”[72] they claimed that, among other things, the embryonic obama health plan could achieve extraordinary savings, amounting to hundreds of billions of dollars annually, from federal “investments” in information technology and reduced overhead in health insurance, improved disease management, care coordination, clinical effectiveness, and “pay for performance” and related “delivery reforms.[66] congressional budget office, budgetary and economic effects of repealing the affordable care act, june 2015, https://www. mooney ‘romneycare’ – a revolution that basically worked boston globe june 26, 2011. the legislature made a number of changes to governor romney's original proposal, including expanding masshealth (medicaid and schip) coverage to low-income children and restoring funding for public health programs.[84] the aca’s health insurance subsidies will register an average annual growth rate of 9. this narrowed application is consistent with hhs’ enforcement authority over such health programs and activities, but other federal agencies are encouraged to adopt the standards set forth in this proposed rule in their own enforcement of section 1557” (fn. one of those cases, the pharmaceutical company gilead sciences was sued over the pricing of its hepatitis c drugs. one of those cases, the pharmaceutical company gilead sciences was sued over the pricing of its hepatitis c drugs.[94] the unlimited tax treatment of employer-based health insurance, as the late milton friedman and many other prominent economists have long argued, contributes to excessive health care costs. for example, for private insurance premiums in all markets, premium growth averaged 4. another policy paradox, progressive health reformers have routinely complained that americans spend too much on health care but have embraced a legislative remedy that substantially guarantees ever greater health care spending.[18] “in short,” observes christopher conover, a professor of health policy at duke university, “the law being implemented today is in many ways quite different than the law passed by a very temporary super-majority of democrats back in 2010. as such, it has the potential to trigger costly and widespread disruption in private health insurance markets. insurers and employee benefit managers, who should be alarmed by the prospect of the federal government turning their private health plans into “public accommodations” or “regulated utilities,” need to recognize that the proposed rule’s interpretation of section 1557 reflects obamacare’s basic, underlying philosophy. health insurance, congress should take specific steps to allow personal, portable, and affordable health coverage to flourish. the state's secretary of health and human services, judyann bigby, said, "massachusetts' achievements in health care reform have been nothing short of extraordinary. republicans debate health bill, let’s remember why americans want obamacare repeal. even so, hhs claims that its proposed rule “does not require plans to cover any particular benefit or service,”[19] and includes in the rule a subsequent paragraph stating:Nothing in this section is intended to determine, or restrict a covered entity from determining, whether a particular health service is medically necessary or otherwise meets applicable coverage requirements in any individual case.[10] namarata uberoi, kenneth finegold, and emily gee, “health insurance coverage and the affordable care act, 2010–2016,” u. republicans debate health bill, let’s remember why americans want obamacare repeal.”[5] it then defines “health program or activity” as:[t]he provision or administration of health-related services or health-related insurance coverage and the provision of assistance to individuals in obtaining health-related services or health-related insurance coverage. obama administration’s design for imposing more health care mandates. choosing a low-cost premium plan in the health insurance exchanges usually means paying much higher deductibles. joseph antos of the american enterprise institute and his colleagues have observed:The fundamental problem with reliance on centralized control over a sector of the economy as complex and vast as health care is that no person or bureaucracy could possess the requisite knowledge to properly set the dials of control to achieve the best balance of cost and quality.[18] “in short,” observes christopher conover, a professor of health policy at duke university, “the law being implemented today is in many ways quite different than the law passed by a very temporary super-majority of democrats back in 2010.[27] during the presidential campaign of 2008, senator obama said that the individual mandate to buy federally approved insurance was unfair and unenforceable.’ health care worries are real, and their concerns are practical. for many years, there has been a downward trend in young americans enrolling in health insurance coverage. is an expert in health care policy and frequently is asked to help lawmakers design and draft reforms to the health systems.[43] the cbo recently confirmed this general upward trend: “insurance premiums—the payments made to buy that coverage by enrollees or by other parties on their behalf—are high and rising. the law specifies, for example, that reimbursement for doctors and hospitals is to secure “quality” care or “value” in their transactions with patients, even though there is often profound disagreement among medical professionals on what, in any given case, quality or value may mean in a clinical context in the treatment of specific diseases or medical conditions. to remedy that (and foreclose any future administration adopting similar policies), congress needs to either repeal section 1557 (on the grounds that it is redundant) or amend it to include rules of construction specifying that the section’s prohibitions on discrimination may not be applied in ways that have the effect of regulating health plan designs or superseding the moral or ethical standards of health care providers or the professional medical judgments of clinicians.[45] the fund—which replaced the uncompensated care pool or free care—pays for medically necessary health care for those who do not have access to health insurance, and pays for the underinsured. 2009, making his case to congress for reform, president obama said:My guiding principle is, and always has been, that consumers do better when there is choice and competition.^ "chapter 58 of the acts of 2006, an act providing access to affordable, quality accountable health care". republicans debate health bill, let’s remember why americans want obamacare repeal. the years before the changes in the state law related to the enactment of the federal ppaca, the state still used the free care pool—renamed the health safety net—both as originally intended and to fund the subsidies for free (under 150% of fpl) and almost free (151–300% of fpl) networked health care insurance. and it makes it easier for insurance companies to treat their customers badly—by cherry-picking the healthiest individuals and trying to drop the sickest, by overcharging small businesses that have no leverage, and by jacking up rates., the employer mandate, which requires firms with 50 or more full-time workers to offer federally approved levels of insurance coverage or pay a tax penalty, is the most significant provision affecting business and employment. choosing a low-cost premium plan in the health insurance exchanges usually means paying much higher deductibles.[37] congressional budget office, “an analysis of health insurance premiums under the patient protection and affordable care act,” november 30, 2009, https://www.[65] congressional budget office, the budget and economic outlook: 2016 to 2026, p.

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