The Affordable Care Act Briefing Book by The Public Notice

e l b a d r o f f A t c A e r a C book g n i f brie

DEC

2013

A PUBLICATION BROUGHT TO YOU BY BANKRUPTING AMERICA

WHAT’S INSIDE 1

INTRODUCTION page 6

Key Provisions of the ACA “Fiscal Flare-Up” Infographic Polling on the ACA

ANECDOTES page 26 29

Trader Joe’s Story

PROBLEMS page 40

WHAT’S NEXT page 50

When he was running for president in 2008, then-Sen. Barack Obama (D-Ill.) promised to reform the nation’s healthcare system. After his election in November 2008, the Obama-Biden transition team outlined several principles for reform. Broadly, the Obama-Biden team promised to make the U.S. healthcare system “work for people and businesses.” Under that expansive pledge fell three, more specific, promises: (1) nothing would change if “you” liked “your current health insurance”; (2) premiums would “go down by as much as $2,500 per year”; and (3) there would be choices for “new, affordable health insurance” for uninsured Americans.” 1

1 INTRODUCTION TO THE AFFORDABLE CARE ACT On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (known simply as the “Affordable Care Act”), a 2,409-page bill the president said kept his promise to reform the nation’s healthcare system.2 Legislative action on healthcare reform had begun in early 2009 with roundtables, discussions and hearings on Capitol Hill and at the White House. In November 2009, the Senate Democratic leadership released the draft bill that would eventually come to be the Affordable Care Act (ACA). The Senate passed the bill that December on a 60 to 39 vote.3 After several changes were made – changes that will be detailed later in this paper – the House passed the bill in March 2010.4 The vote was 219 to 212.5 When the ACA was passed, the Congressional Budget Office estimated it would cost about $382 billion over 10 years and would cover 32 million of the nation’s 45 million uninsured. The percentage of the nonelderly population who were insured was expected to increase from 83 percent to 94 percent.6

Today, the CBO estimates the law will cost $1.375 trillion between 2014 and 2023 and will leave tens of millions of residents uninsured.

Today, the CBO estimates the law will cost $1.375 trillion between 2014 and 2023 and will leave tens of millions of residents uninsured.7 One reason for the cost increase: the CBO is now examining a 10-year horizon in which most of the law will be enacted; the time horizon at the time of the original estimate included several years where most of the lawâ&#x20AC;&#x2122;s provisions were not in effect. Additionally, the Affordable Care Act has added nearly 11,000 pages to the Federal Register, the compendium of federal government regulations.8 The U.S. House has made 45 attempts to repeal or defund the Affordable Care Act.9

Key Provisions of the Affordable Care Act The individual provisions of the Affordable Care Act didnâ&#x20AC;&#x2122;t take effect with the presidentâ&#x20AC;&#x2122;s signature; instead, they have been and will be implemented over several years. In this section, we outline, define and provide the implementation dates for major ACA provisions.10

BOSS

Individual Mandate

Employer Mandate

Healthcare Exchanges

Small Business Tax Credits and Subsidies to Individuals

Coverage for Young Adults

New Rules for Insurance Companies

Independent Payment Advisory Board

Expanded Medicaid Coverage

Individual Mandate The Affordable Care Act requires most Americans to have health insurance (either a policy they personally buy or employer â&#x20AC;&#x201C; or government-provided insurance) or face penalties. Though Republicans, and an increasing number of Democrats, support delaying this requirement, at this writing it will take effect in 2014. This requirement would not apply to all Americans. Prisoners, undocumented immigrants or individuals who wouldnâ&#x20AC;&#x2122;t benefit from health insurance because of their religious convictions are exempt. The Kaiser Family Foundation has provided a helpful infographic to determine whether the mandate applies to an individual.11 Importantly, according to Gallup, only 80 percent of uninsured Americans are aware of this requirement. Nineteen percent of the uninsured that were polled were not aware of the requirement.12 Employer Mandate BOSS

The Affordable Care Act requires employers with 50 or more full-time employees to provide their employees with health insurance. In general, if employers choose not to comply, they will pay a $2,000 fee for every employee after the first 30. In other words, an employer with 51 employees who refuses to provide insurance would be forced to pay a $42,000 fine. The Kaiser Family Foundation has provided a helpful infographic for employers who are trying to determine

whether they fall under the mandate.13 This provision was supposed to take effect on Jan. 1, 2014, but in early July 2013, the Obama Administration announced it would delay implementation of the employer mandate for at least one year. In late November, the White House also announced a second delay in the launch of the online small business exchange, until November 2014. 14 Healthcare Exchanges According to the Kaiser Family Foundation, the Affordable Care Act “made broad changes to the way health insurance will be provided and paid for in the United States,” including the creation of “exchanges.” The exchanges are “entities that will be set up in states to create a more organized and competitive market for health insurance by offering a choice of health plans, establishing common rules regarding the offering and pricing of insurance, and providing information to help consumers better understand the options available to them.” 15 It was up to states how to organize these exchanges, which opened on Oct. 1, 2013. Some states chose not to set up exchanges; citizens in those states must use the federal exchange. (National Journal has a graphic on how each state has decided to order their system).16

Small Business Tax Credits and Subsidies to Individuals The Affordable Care Act will offer tax credits of up to 50 percent of employer healthcare costs to small businesses with fewer than 26 employees that provide health insurance to employees. This provision has been partially implemented: qualifying small businesses are currently eligible for tax credits totaling 35 percent of their costs; that percentage will increase to 50 percent in 2014. The law also “provides refundable and advanceable tax credits and cost sharing subsidies” to individuals and families. Families with incomes up to 400 percent of the poverty level are eligible for the subsidies. These provisions will take effect in 2014. In July 2013, the U.S. Health and Human Services Department announced it would not verify eligibility for these subsidies - something it had previously promised to do. Reuters explained: “[F]inal regulations released quietly...by the Department of Health and Human Services (HHS) give 16 states and the District of Columbia, which are setting up their own exchanges, until 2015 to begin random sampling of enrollees’ employer-insurance status. The rules also allow only random—rather than comprehensive— checks on income eligibility in 2014.”17 Opponents of the move said it would result in fraud that could raise the overall cost of the Affordable Care Act. According to The Wall Street Journal, “HHS promises to develop ‘a more robust verification process,’ some day, but the result starting in October may be millions of people

getting subsidies who don’t legally qualify. This would mean huge increases in Obamacare spending.”18 In October 2013, Republicans won some concessions that could improve income verification. Critics said the measures were simply “symbolic” and would not completely prevent fraud. Coverage for Young Adults The Affordable Care Act requires insurance companies to extend dependent coverage for adult children up to age 26 for all individual and group policies. This provision was fully implemented in 2010. New Rules for Insurance Companies The Affordable Care Act prohibits insurance companies from “placing lifetime limits on the dollar value of coverage,” denying coverage to children with preexisting conditions, and placing “annual limits on the dollar value of coverage.” The law also requires insurance companies put an appeals process in place for consumers denied coverage. These provisions were implemented in 2010. By 2014, health insurance companies will also be required to offer coverage to consumers with pre-existing conditions and prohibited from putting annual limits on coverage. Independent Payment Advisory Board The Affordable Care Act established a 15-member Independent Payment Advisory Board (IPAB), which

will make recommendations to Congress for how to “reduce the per capita rate of growth in Medicare spending if spending exceeds targeted growth rates.” Republican leaders in Congress, who want to repeal the provision setting up the board, have refused to make nominations to IPAB.19 Expanded Medicaid Coverage The Affordable Care Act makes anyone who is ineligible for Medicare and under the age of 65 with an income up to 138 percent of the federal poverty level eligible for Medicaid. This expansion will take effect in 2014, but states must choose whether or not to accept this expansion.20 As of late October 2013, slightly more than half (26) of the states are “moving toward” expansion.21 The federal government would provide 100 percent of the funding for this expansion for the first three years. After that it would gradually phase down to 90 percent of funding by 2020.22 One reason many states have not opted to take the match is because local lawmakers are worried about the federal government’s ability to keep its promise to match the funding required by the state to provide coverage to more people. Indeed, in his fiscal year 2013 budget, President Obama proposed “blending the Medicaid funding rates,” a move that would result in a “smaller overall federal contribution to the program, and a larger state-based one.” 23

WHAT DID THE SUPREME COURT RULING ON THE AFFORDABLE CARE ACT SAY AND DO? Almost immediately after the Affordable Care Act was signed, legal challenges began. Those cases wended their way through the federal court system until one, National Federation of Independent Business vs. Sebelius, ended up at the U.S. Supreme Court. The nationâ&#x20AC;&#x2122;s highest court issued its ruling in the case in June 2012, more than two years after the law passed. The Supreme Court considered two questions: the constitutionality of the requirement that individuals have health insurance and the Medicaid expansion. The court found the individual mandate to be constitutional, but the Medicaid expansion to be unconstitutional.24

Individual Mandate The nation’s highest court, in a 5-4 ruling, found this provision was constitutional under the provision of the U.S. Constitution that allows Congress to levy taxes. Americans who do not buy health insurance are assessed a fine under the ACA. The five justices in the majority justified this fine as a tax by arguing it was less than the cost of insurance; the IRS couldn’t collect it through “punitive means”; and, finally, “the mandate does not turn on whether a person intentionally fails to purchase insurance.”25 Broadly, the five justices argued the individual mandate “leaves an individual with a lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice.”26 Medicaid Expansion The Supreme Court found this ACA provision to be unconstitutional under Congress’s power to spend. According to the Kaiser Family Foundation, “The Court ultimately held that the Medicaid expansion is unconstitutionally coercive of states because states did not have adequate notice to voluntarily consent, and the Secretary could withhold all existing Medicaid funds for state non-compliance.” Despite the court’s findings, the Medicaid portion of the Affordable Care Act remained intact; the states now just have the choice whether or not to participate.27

WHEN IT COMES TO OUR ECONOMY, THE ACA IS NOT WHAT THE DOCTOR ORDERED The Affordable Care Act was supposed to be medicine for the American people, but someone must have forgotten to read all the side effects. Here we take a look at the fine print of the bill and what secondary consequences this new law has on the nation’s fiscal health. Side effects include:

$ 1 T R I L L I O N I N N E W TA X E S U N D E R T H E A C A B I L L WHICH MEANS WE GET THINGS LIKE:

A TAX ON CHARITABLE HOSPITALS

PHASING OUT EMPLOYER PRESCRIPTION DRUG DEDUCTION

IT ALSO TAXES:

A TAX ON COMPREHENSIVE INSURANCE PLANS

AND LIMITS:

Biofuels

Blue Cross/Blue Shield Tax Deductions

Insurance Providers

Tax-Advantaged Accounts

Investment Income

Medical Expense Deductions

Medical Device Manufacturers

Flexible Spending Accounts

Individuals not covered (individual mandate)

Deductions on anything the IRS may see lacking “economic substance”

Employers not covered (employer mandate) --AND--

Employers who HAVE covered their employees

SOURCES: Congressional Budget Office, Americans For Tax Reform, The Kaiser Family Foundation, and United States Census Bureau.

D O A M E R I C A N S T H I N K T H E I R FA M I L I E S W I L L B E B E TT E R O R W O R S E O F F U N D E R T H E A F F O R D A B L E C A R E A C T ? ACCORDING TO A NOVEMBER 2013 KAISER FAMILY FOUNDATION SURVEY

32%

41%

THINK THE AFFORDABLE

THINK THEY WILL BE

CARE ACT WON’T MAKE ANY DIFFERENCE IN THEIR LIVES

WORSE OFF UNDER THE LAW.

20%

7% unsure

THINK THEY WILL BE BETTER OFF UNDER THE LAW.

EFFECTS OF THE BILL AS OF 2012, 48 MILLION AMERICANS WERE UNINSURED

CBO says 7 million Americans will lose their coverage under the ACA

NEW TAXES AND FEES IN THE AFFORDABLE CARE ACT According to the U.S. Treasury Inspector General for Tax Administration, the “Tax provisions included in the Affordable Care Act represent the largest set of tax law changes the IRS has had to implement in more than 20 years.”28 Many of these changes will result in higher taxes on Americans. Specifically, the Congressional Budget Office estimates the U.S. Treasury will collect almost $1 trillion new taxes under the bill.29 Here are the new taxes included in the Affordable Care Act, when they will take effect, and (when available) estimates for how much revenue each new levy could raise over the next 10 years:30 1. Tax on Charitable Hospitals. Starting in 2010, charitable hospitals faced a penalty of $50,000 per hospital if they cannot meet certain new requirements put forth by the U.S. Department of Health and Human Services. 2. Economic Substance. The IRS can disallow tax deductions if it does not consider them to have “substance.” This tax, which was implemented in 2010, is expected to raise taxes by $4.5 billion. 3. Biofuels Tax. This levy, which was made retroactive to January 2010, raises taxes by $23.6 billion. 4. Drug Company Sales. This tax was also made retroactive to January 2010 and raises taxes by $22.2 billion. 5. Limiting Blue Cross/Blue Shield Tax Deduction. Also retroactive to January 2010, this tax increase would raise $400 million.

6. Tanning Services. The Affordable Care Act imposed a new 10 percent excise tax on indoor tanning salons. This tax took effect in July 2010 and is expected to raise $2.7 billion. 7. Limits On Tax-Advantaged Accounts. Starting in January 2011, the Affordable Care Act limited the items for which Americans could use their health savings accounts (HSAs), health reimbursement accounts (HRAs), or flexible spending accounts (FSAs). For example, Americans are no longer able to use the pretax dollars saved in these accounts for non-prescription, overthe-counter medications. This new tax would raise $5 billion. 8. Additional HSA Tax. The Affordable Care Act also increased taxes on early, non-medical-related withdrawals from HSAs. This change, which took effect in January 2011, would increase taxes by $1.4 billion. 9. Investment Income. Starting in January 2013, Americans in households that earned more than $250,000 a year paid a 3.8 percent surtax on their investment income. This change, which is expected to raise taxes by $123 billion, kicks in at the $200,000 annual income level for singles. 10. Medicare Payroll Tax. The Affordable Care Act raised the Medicare payroll tax for households earning more than $250,000 a year and singles earning more than $200,000. This change took effect in January 2013 and is expected to raise taxes by $86.8 billion.

11. Medical Device Manufacturers. The Affordable Care Act imposed a 2.3 percent excise tax on medical device manufacturers starting in January 2013. This tax is expected to raise $20 billion. 12. Medical Expense Deduction. Starting in 2013, taxpayers could deduct medical expenses that totaled more than 10 percent of their adjusted gross income. Previously, taxpayers could deduct any expenses beyond 7.5 percent of their adjusted gross income. This change is expected to cost taxpayers $15.2 billion. 13. Flexible Spending Account Cap. This bill caps the amount Americans can put into their FSAs at $2,500 a year. This provision took effect in January 2013 and is expected to raise $13 billion. Previously, taxpayers could put an unlimited amount of funds in their FSA. 14. Employer Prescription Drug Deduction. In 2013, the Affordable Care Act repealed the deduction employers could take for providing prescription drug coverage to retirees. This tax increase is expected to raise $4.5 billion. 15. Individual Mandate Tax. Starting in 2014, Americans have to have health insurance or pay a fine that could range from hundreds to thousands of dollars. With the employer-mandate tax (see below), this tax is expected to raise $65 billion. 16. Employers Mandate Tax. Starting in 2015, U.S. employers who have 50 or more full-time employees would have to provide health insurance to their employees. If they do not, they are faced

with a $2,000-per-employee fine. With the individual-mandate tax (see above), this tax is expected to raise $65 billion. 17. Health Insurers. The Affordable Care Act includes a new tax on premiums collected by insurance companies each year. This provision would raise taxes by $60.1 billion. 18. Comprehensive Insurance Plans. Starting in 2018, the Affordable Care Act places a 40 percent excise tax on insurance plans that provide more generous coverage. This measure is expected to cost taxpayers $32 billion. 19. Fee For Covering Employees. Employers who fail to provide health insurance to employees will not only face fines (see number 16 above), but the ACA also assesses a fee for employees who are covered. Insurance companies will technically pay the fee, but it is assumed it will be passed on to employers and their employees through higher premium costs. The $63 fee starts in 2014 and, according to The Wall Street Journal, “will apply to plans covering millions of Americans in 2014. It applies to employers that assume the risk for workers’ medical bills, and many private plans sold by insurers. The fee will be smaller for 2015 and 2016, though regulators haven’t set those amounts.” The new tax is expected to raise $25 billion over just three years.31 According to one estimate, at least seven of these new taxes could hit Americans who earn less than $250,000 a year.32 In his 2008 presidential campaign, Barack Obama promised not to raise taxes on Americans who fall into this income category.

POLLING ON THE AFFORDABLE CARE ACT The Kaiser Family Foundation, which provides healthcare policy analysis, has conducted almost-monthly polls on Americans’ views of the Affordable Care Act since the legislation was passed in March 2010. The polls are taken from a large pool of adults (as opposed to likely or registered voters) and are “weighted to balance the sample demographics to match estimates for the national population data from the Census Bureau’s 2011 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), and region along with data from the 2010 Census on population density.” 33

Broadly-speaking, how do Americans feel about the Affordable Care Act?

33% FAVORABLE VIEW

49% UNFAVORABLE VIEW

18% UNSURE

First of all, generally between 15 percent and 25 percent of adults have said they don’t know how they feel about the law. After taking those individuals into account, since the law was passed the percentage of Americans who feel warmly about the bill and those who do not has been roughly the same. Until recently. In its latest poll (from November 2013), the Kaiser Foundation found only 33 percent of Americans have a favorable view of the law while 49 percent have an unfavorable view. In Kaiser’s April 2010 poll (taken the month after the bill passed), 46 percent of adults had a favorable view of it while 40 percent had an unfavorable view.

Do Americans think they will personally be better off under the law?

20% YES

32% NO

41% NO DIFFERENT

No. In Kaiser’s most recent survey (November 2013), only 20 percent of Americans said they believe they will be better off under the law. That number has dropped dramatically from the months after the bill’s passage. In April 2010, 31 percent of Americans thought they would be better off personally. Today, 32 percent of Americans think they will be worse off under the law. The figure is identical to 32 percent in April 2010. The plurality expects to be neither better nor worse off: today, 41 percent think the Affordable Care Act won’t make any difference in their lives, up from

just 30 percent in April 2010. Additionally, in October 2013, only 14 percent of Americans said they had already benefited from the law; 82 percent said they had not.34

Do Americans Think The Country Will Be Better Off Under The Law?

34% YES

43% NO

15% NO DIFFERENCE

The numbers are slightly better here, but the most still say the answer is no. In Kaiser’s most recent survey (November 2013), only 34 percent of Americans said they believe the country will be better off under the law. That number has also dropped dramatically from the months after the bill’s passage. In April 2010, 45 percent of Americans thought the country would be better off with the Affordable Care Act in place. Today, 43 percent of Americans think the country will be worse off under the law, up from 35 percent in April 2010. Fifteen percent think the Affordable Care Act won’t make any difference to the country, up slightly from 11 percent in April 2010.

How Do Americans Feel About Certain Portions Of The Law?

32% SUPPORT IND MANDATE

MAJORITY DOES NOT

According to an earlier Kaiser survey, a very large majority of Americans oppose the requirement that individuals be covered by health insurance. Only 32 percent support the requirement that individual must carry health insurance coverage.35

How Is The Federal Government Doing With Implementation?

12% GOOD

32% FAIR

48% POOR

According to Kaiser, 48 percent of adults think the federal government has done a poor job implementing the Affordable Care Act; 32 percent think it has done a fair job; 12 percent think it has done a good job; and only two percent think it has done an excellent job.36

What Do Americans Want Congress To Do?

22% EXPANDED

25% LEAVE AS-IS

13% REPEAL

24% REPEALED (& NOT REPLACED)

Despite their negative or mixed feelings about the Affordable Care Act, most Americans are willing to let the law stand. According to the October 2013 Kaiser survey, 22 percent of Americans want the law expanded, 25 percent want it kept as is, 13 percent want it repealed and replaced with a Republican alternative, and 24 percent want it repealed and not replaced. (Sixteen percent werenâ&#x20AC;&#x2122;t sure what they wanted Congress to do.)37 These numbers actually represent a shift from the first time Kaiser asked this question, in January 2011. At that point, 28 percent of Americans wanted the law expanded, 19 percent wanted it kept as is, 23 percent wanted it repealed and replaced with a Republican alternative, 20 percent wanted it repealed and not replaced and just 10 percent were uncertain. These numbers suggest there is some general fatigue when it comes to repeal efforts.

2 ANECDOTES FROM EVERYDAY AMERICANS & BUSINESSES WHAT ARE THE EFFECTS OF THE AFFORDABLE CARE ACT? Now that many of Affordable Care Act provisions have taken effect or are close to taking effect, it’s possible to gather anecdotal evidence of its effects. Has the law kept President Obama’s three promises (to allow Americans with coverage to keep it if they wanted, to reduce premiums and to offer affordable coverage to the currently uninsured)? Additionally, will more Americans be covered under this law? And how has and will the law affect the nature of work in America? In this section, we attempt to provide answers to those questions.

MILLIONS OF AMERICANS HAVE OR COULD LOSE THEIR INSURANCE. President Barack Obama and members of his administration routinely promised that Americans would be able to keep their current healthcare coverage if they wanted to. That claim was false and it now appears that millions of Americans will lose their existing health plans.

...as many as 52 million Americans could lose their current healthcare coverage.

52 Million Americans could lose their current healthcare coverage. According to an analysis by McClatchy, as many as 52 million Americans could lose their current healthcare coverage. The wire service noted a 2010 Obama Administration reform “said that as many as 69 percent of certain employerbased insurance plans would lose that protection, meaning as many as 41 million people could lose their plans even if they wanted to keep them and would be forced into other plans.” Additionally, “Another 11 million who bought their own insurance also could lose their plans.”38 CBO said seven million will lose coverage. According to the Congressional Budget Office, about seven million Americans will lose their current health insurance as a result of the Affordable Care Act.39

As of early November 2013, more than 3.5 million Americans had lost coverage. The Associated Press on Nov. 2 offered a state-by-state list of consumers who had already lost their current healthcare coverage. Many states had not revealed information yet, but information from the states that had revealed 3.5 million consumers had lost coverage just one month after the federal exchange was launched.40 Companies have moved current retirees off current coverage to exchanges. “Insurance exchanges are the health-care experiment du jour. Retirees are the test case. The latest indication: Media-company Time Warner Inc. plans to move its U.S. retirees from company-administered health plans to private exchanges, according to a person familiar with the matter. The company will allocate funds in special accounts that retirees can use to go shop for coverage, the person said. The news comes as International Business Machines Corp. also plans to move about 110,000 of its own retirees off its company-sponsored health plan to a Medicare insurance exchange. President Barack Obama’s health-care overhaul calls for such exchanges, which will go live next month, and employers are looking at similar, privately administered exchanges as an alternative to offering their own health plans.” 42 Tax on high-cost insurance plans will result in employees being offered less generous coverage. “The Affordable Care Act includes a tax on high-cost insurance plans that’s both a funding mechanism for the law and meant to encourage patients with a menu of generous health benefits to choose only

Trader Joe’s Employees Lose Current Insurance “After extending healthcare cov era ge to ma ny of its par t-t ime em plo yee s for years, Trader Joe’s has told workers who log fewer than

30 hours a week that they will need to find insurance on the Obamacare exchanges next year, according to a

confidential memo from the grocer’s chief executive. In the me mo to sta ff dat ed Aug . 30, Tra der Joe ’s CE O

Dan Bane said the company will cut a part-timer a check for $500 in Jan uar y and he lp gu ide the m tow ard

finding a new plan under the Afford abl e Car e Act . The company will continue to offer health coverage to workers who carry 30 hours 41 or more on average.”

necessary services...if employers try to avoid the tax by shifting to less generous plans, workers will likely suffer when it comes to their overall compensation, even if they get a boost in wages to make up for the lost health benefits, according to EPI. What’s more, those workers who need medical care would end up with higher out-of-pocket costs.” 43 Other provisions could also result in employers offering less generous plans. “Employers are increasingly recognizing they may be able to avoid certain penalties under the federal health law with very limited plans that can lack key benefits like hospital coverage. Benefits advisers and insurance brokers—bucking a commonly held expectation that the law would broadly enrich benefits—are pitching these low-benefit plans around the country. They cover minimal requirements such as preventive services, but often little more. Some of the plans wouldn’t cover surgery, X-rays or prenatal care at all. Others will be paired with limited packages to cover additional services, for instance, $100 a day for a hospital visit.”44 Reducing family coverage. “The ACA is accelerating a trend toward reducing family coverage that has been in place for a number of years at companies of all sizes as employers try to cut costs, according to health insurance brokers. But family coverage is particularly in jeopardy at small companies.”45

Healthy consumers could see insurance rates double or even triple when they look for individual coverage under the federal health law later this year.

PREMIUMS AND OTHER HEALTHCARE COSTS, INCLUDING TAXES, HAVE RISEN. When he proposed his healthcare plan on the 2008 campaign trail, then-Sen. Barack Obama promised the average premium would fall by $2,500. In fact, costs are rising. Healthy consumers who buy insurance through individual market could see health insurance rates double or triple. “Healthy consumers could see insurance rates double or even triple when they look for individual coverage under the federal health law later this year, while the premiums paid by sicker people are set to become more affordable, according to a Wall Street Journal analysis of coverage to be sold on the law’s new exchanges.”46 Farmers could pay higher costs. “Farmers who aren’t directly subject to national healthcare reforms for employees may still end up with higher labor costs from the overhaul, experts say. ‘This is going to be a huge challenge for a lot of

farms,’ said Leon Sequeira, an attorney with the Seyfarth Shaw law firm who is studying the effects of the Patient Protection and Affordable Care Act, commonly known as Obamacare.”47 Young men aged 25 to 36 will pay at least 50 percent more. “Taken together, men ages 25 to 36 could see rate increases greater than 50%, according to [consulting firm]...”48 Older, sicker households will pay higher taxes because of limits on flexible spending accounts. “[O]ne of Obamacare’s hidden taxes — a new limit on contributions to health flexible spending accounts, or FSAs — will hit older and chronically ill individuals hardest. … In a 2012 study published in Forum for Health Economics & Policy James Cardon, Mark Showalter and Joel Moore examined patterns of FSA usage by income and health status from 1998 to 2008. They found that of the estimated 13.9 million households nationwide with an FSA, 35% will be affected by the new FSA cap, with an average tax increase of $101 in 2013. By 2020, an estimated 41% of FSA households will hit the FSA cap because medical costs will rise faster than the inflation-indexed limit on contributions. Further, this tax burden will be highly skewed. The study found that among FSA-eligible households from 2004 to 2008, those who rank among the top 10% of contributors would have paid 66% of the additional tax if the cap were in place. And which households are most likely to set aside thousands a year for out-of-pocket health expenses? The sick. In fact, nearly twothirds of these households included individuals with three or more chronic health conditions.”49

UNINSURED AMERICANS STILL LACK CHOICES. The Obama Administration also promised that the Affordable Care Act would result in more choices for consumers. In fact, it has resulted in fewer choices. Affordable care act will leave 30 million without insurance. “When we talk about the Affordable Care Act, we mostly focus on the millions of Americans who will gain health insurance coverage. We talk less about the millions who will remain uninsured. And there are a lot of them: 30 million Americans will not have coverage under Obamacare, according to a new analysis in the journal Health Affairs.”50 Top hospitals have opted out of Obamacare. According to Fox News, “Watchdog.org looked at the top 18 hospitals nationwide as ranked by U.S. News and World Report for 2013-2014. We contacted each hospital to determine their contracts and talked to several insurance companies, as well. The result of our investigation: Many top hospitals are simply opting out of Obamacare.”51

More than a year before the employer mandate kicks in, it is clear that it will lead to lost jobs and a move from full-time work to part-time.

AFFORDABLE CARE ACT WILL CHANGE THE NATURE OF WORK IN THE U.S. When the Affordable Care Act was debated in 2009 and 2010, a discussion of how the employer mandate would affect the nature of employment in this country was largely absent. More than a year before the employer mandate kicks in, it is clear that it will lead to lost jobs and a move from full-time work to part-time. 4.2 million Americans may quit their jobs. “A new study distributed by the National Bureau of Economic Research finds that 4.2 million Americans might quit their jobs after January 1, 2014, as they’re able to get affordable health insurance through one of the public exchanges to be set up under Obamacare.”52 In an attempt to avoid employer mandate, businesses could shift employees from full-time to part-time. “Hiring is exploding in the one corner of the U.S. economy where few want to be hired: Temporary work. The number of

temps has jumped more than 50 percent since the recession ended four years ago to nearly 2.7 million - the most on government records dating to 1990. In no other sector has hiring come close. Driving the trend are lingering uncertainty about the economy and employers’ desire for more flexibility in matching their payrolls to their revenue. Some employers have also sought to sidestep the new healthcare law’s rule that they provide medical coverage for permanent workers. … The use of temps has extended into sectors that seldom used them in the past - professional services, for example, which include lawyers, doctors and information technology specialists.”53 Fast food restaurant workers have already had hours cut. “Because a 30-hour work week counts as full-time under Obamacare, Fatburger fast-food restaurants had started cutting worker hours below that threshold, CEO Andy Wiederhorn said. Some Fatburger owners even began ‘job sharing’ with other businesses, teaming up to share a higher number of employees all working fewer hours. Someone could work 25 hours at one Fatburger, 25 at another one with a different franchise owner, and still not be a full-time worker under Obamacare rules. Many companies at the International Franchise Expo in New York City last month acknowledged they’ve been adopting that slash-and-share method, cutting hours and splitting workers.”54

Who would want to invest in a highly-regulated, governmentcontrolled industry that faces a unique tax? What startup medical device company can reach the magical breakeven point with a tax on its revenue?

OTHER POTENTIAL CONSEQUENCES AND STORIES FROM THE OBAMACARE FRONT. Obamacare will lead to venture capital funding to medical device industry drying up – a move that will harm innovation and health. “On Jan. 1, manufacturers of medical devices in the U.S. were hit with a new 2.3% tax on revenue, one of the many sources of money tapped to pay for Obamacare. This tax will likely cut into the profits of large medical-device manufacturers, a cost that will almost certainly be passed on to health-care consumers. But its effect on U.S. medicaldevice startups—the small companies that fuel innovation—may prove devastating. Coincident with the 2.3% tax, venture capital investment in medical devices has all but ceased. Why? Ask yourself two questions: Who would want to invest in a highly-regulated, government-controlled industry that faces a unique tax? What startup medical device company can reach the magical break-even point with a tax on its revenue? … Unless the federal government changes the 2.3% revenue

tax, and until the Patent Office and the FDA improve their turnaround time for regulatory decisions, medical-device startups in the U.S. are all but doomed. For the sake of medical innovation and the future of healthcare, our lawmakers should repeal this damaging tax immediately.”55 Low-Income Americans could find it harder to find a doctor or get preventative care. “As millions of low-income adults gain access in just a few months to Medicaid coverage under Obamacare, those already in the program could be shut out of some of the key preventive services included in the law. And the new enrollees could have a hard time actually getting a doctor. Those are the findings of two Health Affairs studies...Even new Medicaid enrollees could find it difficult to get care, a second Health Affairs study shows. About 30 percent of doctors’ offices didn’t accept new patients who had Medicaid—which typically provides lower reimbursement rates than private insurance and Medicare—in 2011 and 2012, according to Sandra Decker of the National Center for Health Statistics. Medicaid enrollees in Alabama, California, Michigan and New Jersey had the hardest time finding a new primary-care doctor. Psychiatrists, dermatologists and internists were the least likely to accept new Medicaid patients.”56 Obamacare will exacerbate the U.S. physician shortage. “The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the healthcare law, the shortfall of doctors in 2025 would still exceed 100,000.”57

Exchanges lack ability to validate exemptions. “Think you’re exempt from Obamacare’s individual mandate? Good luck proving it. The health law’s least popular component — the requirement to obtain insurance or face a tax penalty — also features a lengthy list of exceptions for people facing certain hardships like foreclosure, domestic violence or homelessness. Members of certain religious sects or Native American tribes also are exempt.”58 Congressional officials may still be exempt. “The Senate may still have a reputation as a genteel club, but lawmakers seemed to abandon rules of decorum completely last week in arguments about whether Congress should be treated like the rest of the country when it comes to Obamacare. Senator David Vitter, a Louisiana Republican, has demanded a floor vote on his bill to end an exemption that members of Congress and their staffs are slated to get that will make them the only participants in the new Obamacare exchanges to receive generous subsidies from their employer to pay for their health insurance.”59

3 PROBLEMS WITH EXCHANGE ROLLOUT TECHNICAL ISSUES WITH ONLINE EXCHANGE ROLLOUT When the online health exchange markets opened on Oct. 1, 2013, they were plagued with technical issues. Users were not able to log onto the exchange, personal profile information was not saved, and users received the wrong premium prices. Here are a few of the top complaints users have had with the HealthCare.gov website: Users unable to log in. According to Consumer Reports, an independent magazine that reviews and compares consumer products and services, thousands of consumers were not able to sign up when the site opened on Oct. 1. The magazine said, â&#x20AC;&#x153;Of the 9.47 million people who tried to register in the first week, only 271,000 were able to create an account.â&#x20AC;? This means that about 1 in 35 people were not able to gain access to site without encountering some error message. Some of the initial problems

“...about 1 in 35 people were not able to gain access to site without encountering some error message.”

people experienced were improper error messages while creating a username, the inability to receive a “account verification” email or users reaching blank loading pages during the identity confirmation portion.60 Further, the Department of Health and Human Services had to reset all usernames and passwords amidst the glitches and bugs in the site. Technology news and information source Ars Technica reported on Oct. 8, “Potential registrants talking to phone support today have been told that all user passwords are being reset to help address the site’s login woes.”61 Information entered is not received correctly. Another complaint users had is that some insurers’ applications lack key pieces of information on transferred forms such as full names or identification numbers.

As a result, some reports indicate insurers have received completely faulty data from the exchanges. Bloomberg noted, “The companies are receiving electronic files that can’t open or have so much missing information on new enrollees they’re unusable.” Some insurers have fixed entries by hand. While it is possible to manually correct entries now, the increasing number of potential enrollees in coming months means this solution is a temporary one.62 Insurers cannot access information for direct sign-up option. Consumers who want to avoid the federal health exchange site have the ability to sign up directly with an insurance company. However, insurers also have not been able to properly access the exchanges’ IT infrastructure. Insurers, who should be able to connect with a universal data center or “hub” to determine if users qualify for certain subsidies, or taxpayer assistance, cannot. Insurers were quiet about these problems and when they would be addressed.63 New subsidy verification process causing traffic jams. The exchange websites prompted users to apply for subsidies before reviewing premium prices. While private sites, such as eHealthInsurance. com, allow users to view plan prices before applying, the federal exchange has potential beneficiaries fill out personal information first.64 According to The Wall Street Journal, this process means users send information across three data centers, CGI Group (the HealthCare.gov developer), UnitedHealth Group Inc. and Experian PLS, a credit check service. If one of these sites fails, the whole system is jammed and creates a “bottleneck” traffic effect.65

BROKEN PROMISES The Affordable Care Act has left a trail of broken promises behind it. These include promises that the website would work seamlessly on Oct. 1 – followed up by promises that it would be fixed in a timely manner. Administration is rushing to fulfill promises.... Instead of stopping traffic to the site altogether, HHS plans to fix problems while the site continues to operate. While experts have been called in to address existing problems, the administration is also adding on new features. The website now features an add-on Spanish-language site, as well as “apply by phone” and “see plans now” buttons. However, while the sites creators have added new features, a potential enrollee still has to scroll through seven pages to see a price.66

“Some specialists working on the project said the online system required such extensive repairs that it might not operate smoothly until after the Dec. 15 deadline for people to sign up for coverage starting in January.”

...which might not be fulfilled until after the December 15th deadline. By Oct. 20, 2013, federal contractors and other Silicon Valley tech experts had started to identify some of the major problems with the website. However, when asked when the problems could be fixed, contractors suggested Dec. 15 may be too ambitious. The New York Times reported, “Some specialists working on the project said the online system required such extensive repairs that it might not operate smoothly until after the Dec. 15 deadline for people to sign up for coverage starting in January.” Additionally, some experts called in to make improvements to the site have said that initial account and registration issues are “masking” larger problems that will come up later.67

CONTRACT CRONYISM In 2007, CGI Federal, a unit of Montrealbased CGI Group, was contracted for “open-ended technology services” with a place-holder value of $1,000. Of the 31 companies fighting for the contract, CGI finally secured the bid and in September 2011 was awarded the extension to

build HealthCare.gov. The new bid was considered an extension of the previous contract because it fell under the same agreement for CGI to provide IT services to CMS. In September 2011, CMS awarded CGI with $55.7 million for its first year of work building the site with an optional three-year extension. This would bring the total potential value of the contract to $93.7 million. However, according to CGI spokeswoman Linda Odorisio, the contract limit was nearly reached by August 2012. Reuters reported that the 2013 bills grew exponentially, costing $27.7 million more in April, $58 million more in May and $18.2 million more in mid-September. Overall, the total spending for CGI to build the website is now at $196 million with some estimates putting the final value at $292 million.68 Government reviewed only one contract to construct national exchange website. In 2007 CGI was given the contract status of “Indefinite Delivery and Indefinite Quantity” or ID/IQ, a fast-track approval process. With this label, CGI became eligible for multiple awards without having to alert the public or open a contract up for competitive bidding. According to USASpending.gov, CGI was awarded 185 separate task orders for work between 2009 and 2013. The total awarded to the company was $678 million and was for work of all kinds. The award to build the HealthCare.gov site was for $93.7 million.69 Failed contract causes government to enlist more outside help. When it became clear CGI clearly couldn’t handle the contract, the Obama administration enlisted “the best and brightest” tech experts

from both government and private companies to fix the problems. Other than saying the team of experts for this “tech surge” would include “veterans of top Silicon Valley companies” the Obama Administration has not revealed what this surge entails or the costs of it.70

POTENTIAL OPPORTUNITIES FOR FRAUD In the rush to get the website operating, the administration has left several security holes. Lack of oversight in the program has left users unprotected against identity theft, false site navigators and assisters. HHS has also engaged in questionable hiring practices like allowing convicted felons to help consumers navigate the site. In addition to these “navigators,” the administration has also set up a program called the In-Person Assistance Program (Assisters). Through this program, the government can use an endless amount funds to hire groups to educate

Scam artists have claimed to be part of the Affordable Care Act’s Navigator and Assister programs and have used this story to steal personal information.

users about the enrollment process. The problem is that the more helpers that are brought in, the harder it will be to discover fraud.71 Below are a few ways fraud has been identified in the program: Users’ identities stolen. Scam artists have claimed to be part of the Affordable Care Act’s Navigator and Assister programs and have used this story to steal personal information.72 According to The Washington Post, “In Maryland, scam artists have started calling residents claiming they need to verify Medicare ID and Social Security numbers for purposes associated with the health law...”73 According to Tennessee Department of Commerce and Insurance, “Another common ruse involves unsolicited calls from scammers who claim to have a ‘ObamaCare Insurance Card’” for the person that picks up the phone. Potential victims are then asked for their credit card numbers, bank account information and Social Security numbers.

Whenever you’re talking about that number of people [involved] and that amount of economic activity, there’s always the opportunity for knuckleheads and criminals to come into that space and try to rip people off.

Because the administration is trying to actively educate citizens about the Affordable Care Act, it is very difficult for potential beneficiaries to differentiate between a scam and a legitimate source.74 Fraudulent websites created. In California, at least one website claiming to house the official state exchange has been shut down. The fake site was titled “California Covered” (the real name of the program is “Covered California”) and was fortunately shut down before the real site opened on Oct. 1. California Insurance Commissioner Dave Jones noted, “Whenever you’re talking about that number of people [involved] and that amount of economic activity, there’s always the opportunity for knuckleheads and criminals to come into that space and try to rip people off. We care very deeply about fraud at the Department of Insurance.”75 Unauthorized fees issued. According to some news sources, fraudulent navigators have also offered to walk users through the enrollment

process for a fee. Tennessee Department of Commerce and Insurance spokeswoman Kate Abernathy noted, “One of our navigator agencies let us know that there was an individual calling people saying that he or she could have walked him through the application process for $100 for a navigator certified application counselor service, but that information is completely incorrect. That is a free service that is supposed to remain free.” Also according to Abernathy, users have been prompted to confirm Medicare numbers, which grants access to more personal information.76 Lack of oversight in the HHS Navigator hiring/training process. HHS has demonstrated poor oversight throughout the hiring and training process. It has opted not to run background checks for Navigators and Assisters and refuses to permit anyone with serious criminal backgrounds from obtaining access to potential beneficiaries’ information. Additionally it has “outsource[d] the authentication, registration, and certification to the Navigator and Assister organization” and refuses to maintain a list of the names of certified Navigators, which will make it impossible for consumers to verify whether they are speaking to an authorized Navigator.77 Convicted felons are also allowed to act as Assisters and Navigators. In Kansas the Director of Outreach and Enrollment for the Heartland Community Health-care-Center (HCHC) was revealed to have a spotty financial history including a bankruptcy in 2003 and a 2007 civil charge for writing a bad check. The employee also was allegedly more than $1,700 behind in state taxes and had an outstanding arrest warrant in Shawnee County.78

4 WHATâ&#x20AC;&#x2122;S NEXT FOR THE AFFORDABLE CARE ACT? At the end of the government showdown in October 2013 it seemed efforts to repeal the Affordable Care Act, in full or in part, had stalled. Up to that point, as noted before, the Republican-held U.S. House had voted to repeal or defund the Affordable Care Act 45 times. Public opinion polls and the news media seemed to indicate Americans had had enough and that Democrats had triumphed in their efforts to preserve the law. But after the government reopened, focus shifted to persistent problems with the federal exchange website, HealthCare,gov, and the realization that as many as 52 million Americans could lose their current health insurance under law whether they wanted to or not. The Obama Administration had promised dozens of times that the website would work flawlessly when it went live on Oct. 1 and had also promised Americans repeatedly in the run up to the lawâ&#x20AC;&#x2122;s passage that they could keep their current coverage if they wanted.79 While under Democratic control, the U.S. Senate still remains unlikely to take up measures aimed at full repeal of the law there is at least a movement afoot by House Democrats to delay certain portions of the law, including the individual mandate. At this writing, nine House

With the 2014 elections just 12 months away, and employers and insurance companies making decisions about employee hours and individual coverage, repeal will continue to be focus of the discussion.

Democrats have signed onto a bill (H.R. 3425) offered by Rep. Dan Lipinski (D-Ill.) to delay the mandate. Additionally, there is still widespread bipartisan support to repeal the medical device tax.80 With the 2014 elections just 12 months away, and employers and insurance companies making decisions about employee hours and individual coverage, repeal will continue to be focus of the discussion. Congress, of course, has already made some changes to the law. According to The Washington Post, Congress has already: > Repealed a provision that would have increased small businesses tax reporting requirements; > Changed who will be eligible for the tax subsidies created by the bill; > Cut off funding for new, nonprofitbased healthcare plan; and > Reduced funding a Prevention and Public Health Fund.81

According to U.S. House Ways and Means Committee Chairman David Camp (R-Mich.) these efforts, and others, have saved taxpayers $52 billion.82 Additionally, in July 2013, the Obama Administration announced it would delay for one year the requirement that employers with more than 50 employees provide health insurance coverage or face a fine. Efforts to further delay this mandate or repeal it entirely will also continue. Indeed, the day of delay announcement, Bloomberg’s Christopher Flavelle wrote, “[I]t’s almost inconceivable that business groups will be satisfied with just this change. The National Retail Federation wants the employer mandate to apply only to businesses with 100 or more full-time employees, not 50. By announcing that it’s willing to budge on timing, the administration weakens its ability to resist more substantial changes, such as reducing the mandate’s scope. This change could make the politics worse, not better. The political and policy ramifications of this delay are also obvious. Opponents of other elements of the law – the individual mandate, Medicare payment cuts, exchange subsidies, to name a few – will no longer buy the line that we’re too far along to change now. Trade associations, whose members may have started questioning the return on investment of their Obamacare lobbying campaigns, now have a new mandate of their own: Increase their efforts.”83 In addition to the political complications with delaying the employer mandate, the delay could increase the federal taxpayer cost of the bill. As The Wall Street Journal reports, “The Congressional Budget Office has said an additional 14 million people were projected to get coverage in 2014 because of the law, seven million of them through the exchanges set to open in October…Supporters of the law said people whose employers delayed offering coverage in 2014 might be better off using

the exchanges. ‘It definitely increases the number of people who will be getting coverage on the exchanges, because they won’t be getting coverage from their employer,’ said Jay Angoff, a partner at the law firm Mehri & Skalet and a former Health and Human Services Department official.”84 Additionally, University of Michigan law professor Nicholas Bagley said, “The shift of employees to the exchanges could cost (the government) a boatload…Some people who are ineligible for subsidies, because their employer offers affordable insurance, may attempt to get subsidies on the exchanges. The IRS will have a hard time policing that sort of conduct.”85 More than that, The Journal says the employer mandate delay will increase confusion. In the same report, the newspaper said, “[Q]uestions were raised Wednesday about how the new exchanges would operate in the absence of information from employers about whether they were offering coverage. To get subsidized coverage on exchanges, people are supposed to show they can’t get employer-backed coverage. But without information from employers on their health-insurance offerings— or lack thereof—it isn’t clear how the Internal Revenue Service would determine an individual’s eligibility.”86 Delaying one portion of the law and not others also raised up fairness questions. If employers had an additional year to comply, why shouldn’t individual Americans? This question, along with technological problems with the website and the fact the law failed to keep the promises President Obama made, guarantee debate about the Affordable Care Act will be a political issue for the next several months at least.

Agenda – Health Care, Office Of The President-Elect, Accessed 6/23/13.

Carolyn Mcclanahan, “Cliffs Notes Version Of The Affordable Care Act,” Forbes, 7/9/12.

Roll Call Vote #396: 60-39, U.S. Senate, 12/24/09.

Health Care Reform From Conception To Final Passage, U.S. Senate Committee On Finance, Accessed 6/23/13. 4

Roll Call Vote #165: 219-212, U.S. House Of Representatives, 3/20/10.

Letter To Speaker Nancy Pelosi, The Congressional Budget Office, 3/20/10.

Letter To Rep. Paul Ryan (R-Wis.), Congressional Budget Office, 7/30/13.

Jayne O’Donnell And Fola Akinnibi, “How Many Pages Of Regulations Are In The Affordable Care Act?,” USA Today, 10/25/13. 8

House Votes Repealing Or Defunding The Affordable Care Act, The New York Times, Accessed 11/12/13. 9

Unless otherwise noted, all information in this section is taken from: Health Reform Implementation Timeline, Kaiser Family Foundation, Accessed 6/24/13. 10

The Requirement To Buy Coverage Under The Affordable Care Act, Kaiser Family Foundation, Accessed 11/12/13. 11

U.S. Uninsured More Aware Of Health Insurance Requirement, Gallup, 10/31/13

Employer Responsibility Under the Affordable Care Act, Kaiser Family Foundation, Accessed 11/12/13. 13

Jason Millman, “Small Business Obamacare Online Enrollment Delayed A Year,” Politico, 11/27/13

Explaining Health Care Reform: Questions About Health Insurance Exchanges, Kaiser Family Foundation, 4/1/10. 15

State Decisions On Healthcare Exchanges, National Journal, Accessed 11/12/13.

David Morgan, “U.S. Relaxes Health Law Income, Insurance Status Rule For Exchanges,” Reuters, 7/8/13. 17

Editors, “Obamacare’s ‘Liar’ Subsidies.” The Wall Street Journal, 7/8/13.

Sam Baker, “GOP Won’t Offer Input On Nominees To Controversial ObamaCare Panel,” The Hill, 5/19/13. 19

Status Of State Action On The Medicaid Expansion Decision, Kaiser Family Foundation, 6/20/13.

Where The State’s Stand On Medicaid, The Advisory Board Company, 10/22/13.

Quick Take: Key Considerations In Evaluating The ACA Medicaid Expansion For States, Kaiser Family Foundation, 4/18/13. 23 Avik Roy, “Governors’ Worst Nightmare: Obama Proposed Shifting Costs Of Obamacare’s Medicaid Expansion To The States,” Forbes, 7/9/12. 22

A Guide To The Supreme Court’s Affordable Care Act Decision, Kaiser Family Foundation, 7/1/12.

Ibid.

Affordable Care Act: Implementation Of Key Information Reporting Provisions, U.S. Treasury Inspector General For Tax Administration, 3/29/13. 28

Letter To House Speaker John Boehner, Congressional Budget Office, 7/24/12.

Unless otherwise noted, all information in this section is taken from: Full List Of Obamacare Tax Hikes, Americans For Tax Reform, Accessed 6/27/13. 30

Janet Adamy, “Employers Blast Fees From New Health Law,” The Wall Street Journal, 3/14/13.

Ashlea Ebeling, “ObamaCare’s 7 Tax Hikes On Under $250,000-A-Year Earners,” Forbes, 6/28/13.

Unless otherwise noted, all information in this section is taken from: Kaiser Health Tracking Poll: November 2013, Kaiser Family Foundation, 11/22/13. 33

Kaiser Health Tracking Poll: October 2013. Kaiser Family Foundation, 11/1/13

Data Note, Kaiser Family Foundation, 3/1/12.

Kaiser Health Tracking Poll: October 2013. Kaiser Family Foundation, 11/1/13

Ibid.

Kevin G. Hall And Anita Kumar, “Analysis: Tens Of Millions Could Be Forced Out Of Health Insurance They Had,” McClatchy DC, 11/7/13. 38

The Budget And Economic Outlook: Fiscal Years 2013 To 2023. Congressional Budget Office, 2/5/13.

Editors, “State By State: 3.5 Million Insurance Policies Canceled,” The Associated Press, 11/2/13.

Dave Jamieson, “Trader Joe’s To Drop Health Coverage For Part-Time Workers Under Obamacare: Memo,” The Huffington Post, 9/11/13. 41

Spencer E. Ante, “Time Warner Joins IBM In Health Shift For Retirees,” The Wall Street Journal, 9/9/13. 42

Jillian Berman, “Obamacare Tax Aimed At ‘Cadillac Plans’ Will Hurt Ordinary Workers: Report,” The Huffington Post, 5/8/13. 43

Christopher Weaver And Anna Wilde Mathews, “Employers Eye Bare-Bones Health Plans Under New Law,” The Wall Street Journal, 5/20/13. 44

Joyce M. Rosenberg, “Family Insurance In Jeopardy At Small Companies,” The Associated Press, 8/8/13. 45

Louise Radnofsky, “Health-Insurance Costs Set For A Jolt,” The Wall Street Journal, 7/1/13.

Mateusz Perkowski, “Experts: Obamacare Will Increase Some Labor Costs, Capital Press, 7/2/13.

Tami Luhby, “Who Will Pay More Under Obamacare? Young Men,” CNN Money, 5/14/13.

Tom Miller, “A Hidden Tax In Obamacare,” Los Angeles Times, 5/20/13.

Sarah Kliff, “Obamacare Leaves Millions Uninsured,” The Washington Post, 6/7/13.

Tori Richards, “Top Hospitals Opt Out Of Obamacare,” Fox News, 11/4/13.

Rick Newman, “A New Reason Not To Work,” Yahoo Finance, 7/16/13.

Christopher s. Rugaber,“Temporary Jobs Becoming A Permanent Fixture In The U.S.,” The Associated Press, 7/7/13. 53

Jose Pagliery, “For Fatburger And Others, ObamaCare Delay Came Too Late,” CNN Money, 7/8/13.

Drs. Fred Burbank And Thomas J. Fogarty, “Another Obamacare Tax That Is Bad For Your Health,” The Wall Street Journal, 7/7/13.

Jason Millman, “Study: Some On Medicaid Lose Out Under ObamaCare,” Politico, 7/9/13.

Annie Lowrey And Robert Pear, “Doctor Shortage Likely To Worsen With Health Law,” The New York Times, 7/28/13. 57

Kyle Cheney, “Exemptions Pose Another Big Hurdle For Obamacare,” Politico, 10/15/13

John Fund, “Congress’s Exemption From Obamacare,” National Review, 9/16/13.

How To Successfully Register For Health Insurance On HealthCare.gov, Consumer Reports, 10/16/13. 60

Sean Gallagher, “Obamacare Site Hits Reset Button On Passwords As Contractors Scramble,” Ars Technica, 10/8/13. 61

Drew Armstrong & Alex Nussbaum, “Insurers Getting Faulty Data From U.S. Health Exchanges,” Bloomberg, 10/8/13. 62

Jason Millman & Brett Norman, “Another Obstacle To Signing Up For ACA Crops Up,” Politico, 10/21/13. 63

Avik Roy, “Obamacare’s Website Is Crashing Because It Doesn’t Want You To Know How Costly Its Plans Are,” Forbes, 10/14/13. 64

Christopher Weaver & Louise Radnofsky, “HealthCare.gov’s Flaws Found, Fixes Eyed,” The Wall Street Journal, 10/10/13.

Alex Wayne, Drew Armstrong & Alex Nussbaum, “Obamacare Rushes To End Delays As Deadline Talk Grows,” Bloomberg, 10/21/13. 66

Sharon Lafraniere, Ian Austen & Robert Pear, “Contractors See Weeks Of Work On Health Site,” The New York Times, 10/20/13.

Sharon Begley, “Insight: As Obamacare Tech Woes Mounted, Contractor Payments Soared,” Reuters, 10/17/13. 68

Lydia Depillis, “Meet CGI Federal, The Company Behind The Botched Launch Of Healthcare.Gov,” The Washington Post, 10/16/13. 69

David Morgan & John Whitesides, “Obama Turns To Trusted Aide For ‘Tech Surge’ To Fix Healthcare Website,” Reuters, 10/22/13. 70

Grace-Marie Turner, “Obamacare Workers Offering Help Also Threaten Identity Theft,” Forbes, 9/24/13. 71

Risks Of Fraud And Misinformation With Obamacare Outreach Campaign: How Navigator And Assister Program Mismanagement Endangers Consumers, House Committee On Oversight And Government Reform, 9/18/13. 72

J.D. Harrison, “Using Obamacare As Bait, Scam Artists Target Consumers And Business Owners,”

The Washington Post, 9/10/13. Tdci Says, “Be On Alert For Aca Scammers!”, Tennessee Department Of Commerce And Insurance, 10/16/13. 74

Sam Brock, “Reality Check: Obamacare Fraud Concerns Already Surfacing,” NBC Bay Area, 9/25/13

Chris Butler, “Reports Of Obamacare Fraud Emerge In Tennessee,” Fox News, 10/16/13.

Michael Volpe, “Obamacare ‘Navigator’ In Kansas Has Outstanding Arrest Warrant,” The Daily Caller, 10/14/13. 78

Kevin G. Hall And Anita Kumar, “Analysis: Tens Of Millions Could Be Forced Out Of Health Insurance They Had,” McClatchy DC, 11/7/13. 79

H.R. 3425 – Health Care Access Fairness And Penalty Delay Act Of 2013, THOMAS – The Library Of Congress, Accessed 11/12/13 80

Sarah Kliff, “Yes, The 37th Obamacare Repeal Vote Matters, The Washington Post, 5/16/13.

Republican Efforts To Repeal Obamacare Have Saved More Than $52 Billion, U.S. House Committee On Ways And Means, Accessed 11/12/13.

Christopher Flavelle, “Is Obamacare Headed For Even More Trouble?,” Bloomberg View, 7/2/13.

Louise Radnofsky, Anna Wilde Mathews And Christopher Weaver, “Health-Law Penalty Delay Clouds Individual Mandate,” The Wall Street Journal, 7/5/13. 84

Sharon Begley, “Delay In Obamacare Requirement Puts Onus On The Honor System,” Reuters, 7/5/13. 85

Louise Radnofsky, Anna Wilde Mathews And Christopher Weaver, “Health-Law Penalty Delay Clouds Individual Mandate,” The Wall Street Journal, 7/5/13. 86

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