"There are two Affordable Care Acts. There's the legislation passed by Congress in 2009, and then there's the mythical Affordable Care Act – the perfidious 'government takeover' decried and demagogued by so many conservatives (and quite a few liberals). The former is quite popular, the latter gets decidedly mixed reviews."
Quotes on Patient Protection and Affordable Care Act
"A tax, in the general understanding and in the strict constitutional sense, is an exaction for the support of Government; the term does not connote the expropriation of money from one group to be expended for another, as a necessary means in a plan of regulation...."
"The question in such cases is not what powers the Federal Government ought to have, but what powers have, in fact, been given it by the people. ...
Ours is a dual form of government; in every State there are two Governments -- the State and the United States; each State has all governmental powers save such as the people, by the Constitution, have conferred upon the United States, denied to the States, or reserved to themselves."
"The Government of the United States is a Government of delegated powers; it has only such powers as are expressly conferred upon it by the Constitution and such as are reasonably to be implied from those expressly granted."
"The power to tax and spend is a separate and distinct power; its exercise is not confined to the fields committed to Congress by the other enumerated grants of power, but it is limited by the requirement that it shall be exercised to provide for the general welfare of the United States."
"National health insurance is the most effective single way to meet the Nation's health needs. Because adequate treatment of many illnesses is expensive and its cost cannot be anticipated by the individual, many persons are forced to go without needed medical attention. Children do not receive adequate medical and dental care. Symptoms which should come early to the attention of a physician are often ignored until too late. The poor are not the only ones who cannot afford adequate medical care. The truth is that all except the rich may at some time be struck by illness which requires care and services they cannot afford. Countless families who are entirely self-supporting in every other respect cannot meet the expense of serious illness."
"A national health insurance program is a logical extension of the present social-security system which is so firmly entrenched in our American democracy. Of the four basic risks to the security of working people and their families--unemployment, old age, death and sickness--we have provided some insurance protection against three. Protection against the fourth--sickness--is the major missing element in our national social insurance program."
"Under the [nationalized insurance] program which I have proposed patients can and will be as free to select their own doctors as they are today."
“A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action. The government has never required people to buy any good or service as a condition of lawful residence in the United States. An individual mandate would have two features that, in combination, would make it unique. First, it would impose a duty on individuals as members of society. Second, it would require people to purchase a specific service that would be heavily regulated by the federal government."
"This is also an income shift -- it's a shift, it's a leveling to help lower income Americans. Too often, much of late, the last couple three years the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy, and the middle income class is left behind. Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America, because healthcare is now a right for all Americans, because healthcare is now affordable for all Americans."
"More than 2,500 pages and 500,000 words long, ... the Patient Protection and Affordable Care Act represents the most significant transformation of the American health care system since Medicare and Medicaid. It will fundamentally change nearly every aspect of health care from insurance to the final delivery of care."
"With enactment of the Patient Protection and Affordable Care Act (PPACA), … Congress is imposing a mandate on citizens, effective January 1, 2014, to purchase a federally approved level of health insurance. …
Under Section 1501, individuals will be assessed a monetary penalty if they do not purchase a health insurance plan that meets the federal definition of ‘minimum essential benefits.' Congress finds, in Section 1501(a), that health care is inextricably connected with interstate commerce thus claiming a constitutional power to require that citizens purchase a specified level of coverage. The penalty for failure to make such a purchase is to be the greater of a flat dollar amount or a percentage of income, phased in from 1 percent to 2.5 percent of income by 2016. The penalty is to be phased in over a three-year period, with the flat dollar amount set at $95 in 2014, $325 in 2015, and $695 in 2016."
"The constitutional fight over ObamaCare reaches far beyond medicine. At issue is protection of individual liberty. Are there any limits left to Washington's reach?"
"The congressional mandate on American citizens to purchase health insurance is unprecedented. ... It is one of the most controversial provisions of the new law, ... setting off a record number of state lawsuits and launching a large number of state legislative countermeasures. ... The Administration has also been inconsistent, with President Obama originally opposing an individual mandate ... but then endorsing it. The President stated that the penalty was not a tax, but then Administration lawyers insisted it was, stressing that Congress’s 'sweeping' taxing power was 'the linchpin' of their argument for the mandate’s constitutionality. ... Certain propositions are increasingly clear.
It Is an Unconstitutional Violation of Personal Liberty and Strikes at the Heart of American Federalism."
"It is with great humility and with great pride that we tonight will make history for our country and progress for the American people. ... Just think–we will be joining those who established Social Security, Medicare, and now tonight health care for all Americans. ...
In doing so, we will honor the vows of our founders, who in the Declaration of Independence said that we are 'endowed by our Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness.' This legislation will lead to healthier lives, more liberty to pursue hopes and dreams and happiness for the American people. This is an American proposal that honors the traditions of our country."
"The top-down federal approach to health care reform assaults the traditional state role in insurance regulation, squashes innovation, and undermines real choice and competition. PPACA is thus a bad deal for states, reducing them to mere agents of federal health and insurance policy."
"The Affordable Care Act is not just a law designed to cover the majority of our nation’s uninsured, moving us into the league of industrialized nations which guarantee universal health coverage for its citizens. The law also takes the crucial first steps toward reining in our runaway health care costs. It ends discriminatory insurance practices that leave many of our citizens one bad gene, or badly timed accident, away from personal bankruptcy. It does so while introducing insurance market competition that will lead to lower health insurance premiums for some, and better coverage for others, in the so-called nongroup insurance market where workers without employer-provided health insurance turn for coverage. The Affordable Care Act does all this while significantly reducing our enormous federal budget deficit over the next 10 years."
"The Patient Protection and Affordable Care Act (PPACA) ... imposes numerous tax hikes that transfer more than $500 billion over 10 years—and more in the future—from hardworking American families and businesses to Congress for spending on new entitlements and subsidies. In addition, higher tax rates on working and investing will discourage economic growth both now and in the future, further lowering the standard of living."
"If the new Congress wants to improve health care quality and lower costs, it should do what it can to support all the cost-containing measures in the already-enacted law."
"One of the central goals of the Patient Protection and Affordable Care Act (PPACA) ... was to increase the number of individuals with health insurance coverage. To encourage employers to offer coverage, the new law creates a tax penalty on firms with more than 50 workers that fail to provide 'adequate' coverage for their employees. The result is government intrusion into voluntary arrangements made between employer and employee.
The cost of the tax penalty will ultimately be borne by workers (lower wages and fewer jobs), shareholders (lower profits), and consumers (higher prices)."
"[The] increased costs that PPACA places on businesses will in turn reduce business growth and hiring. The CBO predicts that PPACA will reduce the amount of labor being used in the economy by approximately one-half of 1 percent. ... This equates to about 700,000 additional Americans being unemployed."
"The exchange with Speaker Pelosi on Thursday occurred as follows:
CNSNews.com: 'Madam Speaker, where specifically does the Constitution grant Congress the authority to enact an individual health insurance mandate?'
Pelosi: 'Are you serious? Are you serious?'
CNSNews.com: 'Yes, yes I am.'"
"The individual mandate is outside Congress' Commerce Clause power, and it cannot be otherwise authorized by an assertion of power under the Necessary and Proper Clause. It is not Constitutional."
"Younger adults will be particularly hard-hit by PPACA’s new restriction on age rating of premiums. The natural variation by age in medical costs is about 5 to 1—meaning that the oldest group of (non-Medicare) adults normally consumes about five times as much medical care as the youngest group. Thus, if an average 64-year-old consumes five times as much medical care as an average 21-year-old, PPACA’s stipulation that an insurer cannot charge a 64-year-old more than three times what it charges a 21-year-old will have the effect of artificially 'compressing' normal age-related premium variations.
This mandated 'rate compression' forces insurers to both under-price coverage for older people and overprice coverage for younger individuals. Actuaries estimate that the effect will be to increase premiums for those ages 18–24 by 45 percent and those ages 25–29 by 35 percent while decreasing premiums for those ages 55–59 by 12 percent and those ages 60–64 by 13 percent."
"Interestingly, the [PPACA] law may have created the worst of both worlds, a mandate that is costly and violates individual liberty, but one that is still weak enough that it may be cheaper for many individuals to pay the penalty than to purchase insurance. As a result it may fall far short of its proponents’ goal of bringing young and healthy individuals, who today frequently forego insurance, into the insurance pool."
"The new health care law has states and citizens lining up — but not quite in the way President Obama or Congress had hoped. Across the country, lawsuits are being filed that could have sweeping implications, not just for health care but our constitutional system. … One of the most contested issues is the so-called individual mandate under which Congress has ordered all citizens to get medical insurance or face fines. Though the federal government has the clear advantage in such litigation, these challenges should not be dismissed as baseless political maneuvering. There is a legitimate concern for many that this mandate constitutes the greatest (and perhaps the most lethal) challenge to states' rights in U.S. history."
"All Americans have a stake in the ongoing constitutional litigation over ObamaCare. First is saving the health care system from Uncle Sam's not so tender mercies. Second is enforcing one of the important limits on national power. If the justices instead rule that the Constitution no longer means what it says, then no Americans' liberty will be secure."
"ObamaCare doesn't reduce medical costs under even the rosiest of scenarios (that is, projections that take seriously all its creators' assumptions). What we can be certain of is that this legislation increases the amount of money taxpayers will be forced by law to pay for health insurance to the tune of $420 billion over the next 10 years. Claims about ObamaCare’s deficit-reduction effects depend on new taxes growing even faster than new spending."
"Perhaps the single most important aspect of the [PPACA] law is its individual mandate, a legal requirement that every American obtain health insurance coverage that meets the government’s definition of 'minimum essential coverage.' Those who don’t receive such coverage through government programs, their employer, or some other group would be required to purchase individual coverage on their own.
This individual mandate is unprecedented in U.S. governance. Back in 1993, when the Clinton health care plan was under consideration, the Congressional Budget Office noted: 'A mandate requiring all individuals to purchase health insurance would be an unprecedented federal action. The government has never required people to buy any good or service as a condition of lawful residence in the United States.' ... Moreover, the individual mandate raises serious constitutional questions. ... Even the Congressional Research Service was not able to conclude it was constitutional!"
"The health care law starts the arduous process of shifting the medical payment system away from an emphasis on quantity of care and toward an emphasis on quality. For example, it creates penalties for hospitals with high rates of readmission and hospital-acquired infections. It expands the practice of making a single payment for treating a specific condition rather than paying for each treatment. And it provides for accountable care organizations that financially bind doctors and hospitals so that they offer the coordinated care that experts believe would save money in complex cases."
"In addition to slow and uncertain revenue growth, contacts in this recovery are frequently citing a number of other factors that are impeding hiring. Prominent among these is the lack of clarity about the cost implications of the recent health care legislation. We've frequently heard strong comments to the effect of 'my company won't hire a single additional worker until we know what health insurance costs are going to be.'"
"The relatively minor provisions of the law that have taken effect to date are already killing jobs, increasing premiums and taxes, reducing take-home pay, causing private-insurance markets to collapse, and throwing Americans out of their health plans. Yet today's cost increases and other dislocations will look like the good old days compared with what Americans will suffer when — if — they allow Obamacare to take full effect. The nonpartisan Congressional Budget Office projects, for example, that Obamacare will permanently eliminate 800,000 jobs by 2021. That's not to mention any temporary job losses."
"Rather than beat their plowshares into swords, Obamacare opponents in most state capitols are laying the bureaucratic foundations for the law's new entitlement spending and lending it legitimacy by accepting its debt-financed federal grants. Secretary of health and human Services Kathleen Sebelius boasts that 48 states have already accepted at least $1 million each from the federal government to help them plan their exchanges."
"Because I find both the 'uniqueness' and 'economic decision' arguments unpersuasive, I conclude that the individual mandate seeks to regulate economic inactivity, which is the very opposite of economic activity. And because activity is required under the Commerce Clause, the individual mandate exceeds Congress’ commerce power, as it is understood, defined, and applied in the existing Supreme Court case law."
"It's not surprising that opponents, having lost in Congress, have taken to the courts. We saw similar challenges to laws that created Social Security and established new civil rights protections. Those challenges ultimately failed, and so will this one.
Rather than fighting to undo the progress we've made, and returning to the days when one out of seven Americans was denied insurance due to their medical histories, supporters of repeal should work with us to implement this law effectively. The initial decisions about the Affordable Care Act will be reviewed on appeal. We are confident that the law will ultimately be upheld."
"If Congress intends to implement health care reform --- and there would appear to be widespread agreement across the political spectrum that reform is needed --- it should do a comprehensive examination of the Act and make a legislative determination as to which of its hundreds of provisions and sections will work as intended without the individual mandate, and which will not. It is Congress that should consider and decide these quintessentially legislative questions, and not the courts."
"The operational feasibility of an individual mandate depends in part on the challenges that must be addressed to implement the mandate. An individual mandate would by definition provide an incentive for individuals to purchase health insurance when they might not have done so otherwise. However, no mandate will result in 100 percent compliance, as has been seen through the limited experience with health insurance mandates in some states and other countries, as well as through experience with mandates in other areas of the law, such as automobile insurance, child support, and taxation ...."
"Another fundamental flaw in our current health care system before passage of the Affordable Care Act was that individuals could 'free ride,' remaining uninsured until they need care and then turning to emergency rooms. Emergency rooms are required by law to provide care to all regardless of insurance coverage. The associated uncompensated care costs of treating these individuals amount to a more than $40 billion a year tax on the insured in the United States.
The Affordable Care Act ends this free riding by requiring that individuals purchase insurance if it is affordable for them (which it will be for most due to the subsidies described earlier). This personal responsibility requirement, originally the brainchild of Republican experts, would end the unfairness of a system where emergency room health care providers are required to treat everyone but individuals are not in turn required to pay their fair share of the costs of treatment. Repealing the new law would mean returning to a world where individuals can simply wait until they are sick to get treated, passing the costs on to the rest of society that is paying their share."
"Widespread failure to purchase health insurance under an individual mandate increases health insurance costs for other members of society and presents practical administrative and financing problems when noncomplying individuals need health care."
"All individuals will be required to have health insurance, with some exceptions, beginning in 2014. Those who do not have coverage will be required to pay a yearly financial penalty of the greater of $695 per person (up to a maximum of $2,085 per family), or 2.5% of household income, which will be phased-in from 2014-2016. Exceptions will be given for financial hardship and religious objections; and to American Indians; people who have been uninsured for less than three months; those for whom the lowest cost health plan exceeds 8% of income; and if the individual has income below the tax filing threshold ($9,350 for an individual and $18,700 for a married couple in 2009)."
"Should everyone be required to have health insurance? The short answer is no. There is nothing that can be achieved with a mandate to buy health insurance that cannot be better achieved by a carefully designed system of tax subsidies. Beyond that, a requirement that everyone obtain insurance (as the new health reform law dictates) creates problems greater than the problem it is designed to solve."
"Right now, the insurer sets the rules. It collects background information on applicants and then varies the price and availability of insurance to discriminate against those who are likely to use it. Health-care reform is going to render those practices illegal. An insurer will have to offer insurance at the same price to a diabetic and a triathlete.
But if you remove the individual mandate, you're caught in the reverse of our current problem: The triathlete doesn't buy insurance. Fine, you might say. Let the insurer get gamed. They deserve it.
The insurers, however, are not the ones who will be gamed. The sick are. Imagine the triathlete's expected medical cost for a year is $200 and the diabetic's cost is $20,000. And imagine we have three more people who are normal risks, and their expected cost in $6,000. If they all purchase coverage, the cost of insurance is $7,640. Let the triathlete walk away and the cost is $9,500. Now, one of the younger folks at normal cost just can't afford that. He drops out. Now the average cost is $10,600. This prices out the diabetic, so now she's uninsured. Or maybe it prices out the next normal-cost person, so costs jump to $13,000.
This is called an insurance death spiral. If the people who think they're healthy now decide to wait until they need insurance to purchase it, the cost increases, which means the next healthiest group leaves, which jacks up costs again, and so forth.
Kill the individual mandate and you're probably killing the bill, too. The mandate is what keeps average premium costs low, because it keeps healthy people in the insurance pool."
"Interestingly enough, Obama has waived the onerous Obamacare rules for quite a few healthcare providers, too. One wonders how good Obamacare could be if the rules are waived for actual healthcare providers?"
"But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy."
"...over 1,000 sponsors of health plans have received waivers from Obamacare’s annual limit requirements. In February 2011, HHS approved 94 percent of waiver applications. The largest waiver thus far is for the United Federation of Teachers Welfare Fund in New York and its 351,000 enrollees."
"In the context of current health insurance market circumstances and the framework of the legislation, the use of an individual mandate, structured as it is to ensure affordability for all who are subject to it, is likewise an eminently rational and well-supported (‘necessary and proper’ in the words of Article I, §8) means for achieving these goals. The same goals and choice of means fit the mandate snugly within precedents broadly defining Congress’ authority to tax and spend.
Opponents’ arguments to the contrary express philosophical objections to the concept of mandatory health insurance in principle, without regard to the practical issues the Supreme Court has always used to evaluate laws challenged as outside Congress’ interstate commerce authority: the practical impact of the mandate on commerce or the public welfare or the welfare of affected individuals, or the rationality of Congress’ judgments about its impact on statutory goals. No doubt, in some quarters, opponents’ libertarian views are deeply felt. But they have no basis in law, neither in the grants of authority to Congress in Article I nor in limitations on that authority in the Bill of Rights, nor in the case law interpreting these provisions."
"The Affordable Care Act is not a government takeover of the U.S. health system; it is a means of using reformed private nongroup insurance markets to more effectively fight the steady decline in employer-provided group insurance. Repeal means a fundamental retreat from the promise of private health insurance coverage for our citizens."
"Within two months of the passage of Obamacare, the job market stopped improving. This suggests that businesses are not exaggerating when they tell pollsters that the new health care law is holding back hiring. ...
The fact that improvements in the job market ground to a halt after Congress passed Obamacare does not prove that the health care law caused it—correlation cannot prove causation. However, the fact does lend strong weight to the voices of businesses who say that the law is preventing hiring.
In a recent survey, 33 percent of business owners said the health care law was either their greatest or second-greatest obstacle to new hiring."
"Properly formulated, we perceive the question before us to be whether the federal government can issue a mandate that Americans purchase and maintain health insurance from a private company for the entirety of their lives. ... These types of purchasing decisions are legion. Every day, Americans decide what products to buy, where to invest or save, and how to pay for future contingencies such as their retirement, their children’s education, and their health care. The government contends that embedded in the Commerce Clause is the power to override these ordinary decisions and redirect those funds to other purposes. Under this theory, because Americans have money to spend and must inevitably make decisions on where to spend it, the Commerce Clause gives Congress the power to direct and compel an individual’s spending in order to further its overarching regulatory goals, such as reducing the number of uninsureds and the amount of uncompensated health care.
In answering whether the federal government may exercise this asserted power to issue a mandate for Americans to purchase health insurance from private companies, we next examine a number of issues: (1) the unprecedented nature of the individual mandate; (2) whether Congress’s exercise of its commerce authority affords sufficient and meaningful limiting principles; and (3) the far-reaching implications for our federalist structure. ...
Both parties have cited extensively to previous Supreme Court opinions defining the scope of the Commerce Clause. Economic mandates such as the one contained in the Act are so unprecedented, however, that the government has been unable, either in its briefs or at oral argument, to point this Court to Supreme Court precedent that addresses their constitutionality. Nor does our independent review reveal such a precedent. ...
What the Court has never done is interpret the Commerce Clause to allow Congress to dictate the financial decisions of Americans through an economic mandate."
"The fact that Congress has never before exercised this supposed authority is telling. As the Supreme Court has noted, 'the utter lack of statutes imposing obligations on the States’ executive (notwithstanding the attractiveness of that course to Congress), suggests an assumed absence of such power.' Few powers, if any, could be more attractive to Congress than compelling the purchase of certain products. Yet even if we focus on the modern era, when congressional power under the Commerce Clause has been at its height, Congress still has not asserted this authority. Even in the face of a Great Depression, a World War, a Cold War, recessions, oil shocks, inflation, and unemployment, Congress never sought to require the purchase of wheat or war bonds, force a higher savings rate or greater consumption of American goods, or require every American to purchase a more fuel efficient vehicle."
In sum, the individual mandate is breathtaking in its expansive scope. It regulates those who have not entered the health care market at all. It regulates those who have entered the health care market, but have not entered the insurance market (and have no intention of doing so). It is overinclusive in when it regulates: it conflates those who presently consume health care with those who will not consume health care for many years into the future. The government’s position amounts to an argument that the mere fact of an individual’s existence substantially affects interstate commerce, and therefore Congress may regulate them at every point of their life. This theory affords no limiting principles in which to confine Congress’s enumerated power."
"[W]e conclude that the individual mandate contained in the Act exceeds Congress’s enumerated commerce power. This conclusion is limited in scope. The power that Congress has wielded via the Commerce Clause for the life of this country remains undiminished. Congress may regulate commercial actors. It may forbid certain commercial activity. It may enact hundreds of new laws and federally-funded programs, as it has elected to do in this massive 975-page Act. But what Congress cannot do under the Commerce Clause is mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time they are born until the time they die.
It cannot be denied that the individual mandate is an unprecedented exercise of congressional power."
"Thus, the text of the individual mandate unambiguously provides that it imposes a penalty. The penalty encourages compliance with the Act’s requirement to obtain 'minimum essential coverage' by imposing a monetary sanction on conduct that violates that requirement. The text is not unclear and was carefully selected to denote a specific meaning."
"The very nature of congressional findings about the individual mandate further amplifies that Congress designed and intended to design a penalty for the failure to comply and not a tax. The source of the power, asserted by Congress, to create the mandate is directly pegged to the Commerce Clause. ...
Indeed, the findings make clear that the goal of the individual mandate is not to raise revenue for the public fisc, but rather to, among other things, reduce the number of the uninsured and to create what Congress perceived to be effective health insurance markets that make health insurance more widely available. ...
Congress repeatedly told us that the individual mandate is a 'penalty' and expressly invoked its Commerce Clause power as the foundation for the mandate. The two are not the same thing. Ultimately, we are hard pressed to construe the statute in a manner that would require us to ignore the plain text of the statute, the words repeatedly employed by Congress, well-settled principles of statutory construction, and well-settled law emphasizing the substantive distinction between a tax and a penalty."
"After careful review of the statute, we conclude that the individual mandate is a civil regulatory penalty and not a tax. As a regulatory penalty, the individual mandate must therefore find justification in a different enumerated power. ...
The individual mandate as written cannot be supported by the tax power."
"'The whole structure of the law collapses without a state-run exchange,'" said Michael Cannon, director of health policy studies at the libertarian Cato Institute. 'That forces Congress to either repeal ObamaCare or significantly alter it.'"
"The commerce clause gives Congress authority to regulate interstate commerce. Since the 1930s, Supreme Court decisions have interpreted the commerce clause broadly. But every previous case expanding the commerce power involved some sort of 'economic activity,' such as operating a business or consuming a product. Failure to purchase health insurance is neither commerce nor an interstate activity. Indeed, it is the absence of commerce.
If Congress could use that clause to regulate mere failure to buy a product on the grounds that such inaction has an economic effect, there would be no structural limits to its power."
"Two years ago, when introducing then promptly enacting Obamacare, the president stated that healthcare law reform would not cost a penny over $1 trillion ($900 billion to be precise), and that it would not add 'one dime' to the debt. It appears that this estimate may have been slightly optimistic… by a factor of 1700%. Because coincident with the recent Supreme Court debacle, in which a constitutional law president may be about to find that his magnum opus law is, in fact, unconstitutional, someone actually read the whole thing cover to cover, instead of merely relying on the CBO's, pardon Morgan Stanley and Goldman Sachs', funding estimates. That someone is Republican Jeff Sessions who after actually running the numbers has uncovered that the true long-term funding gap is a mind-boggling $17 trillion, just a tad more than the original sub $1 trillion forecast. This latest revelation means that total underfunded US welfare liabilities: Medicare, Medicaid and social security now amount to $99 trillion!"
"...while Obama may have been taking creative license with a number that is greater than total US GDP, he was most certainly correct when saying that Obamacare would not add a penny to US debt. Because the second the US government comes to market to fund a true total debt/GDP ratio of 750%, it is game over, and the Fed will have its hands full selling Treasury puts every waking nanosecond to have any time left for the daily 3pm stock market ramp."