IRS Issues Regs on Wellness Program Incentives
Originally posted January 28, 2014 by Jerry Geisel on https://www.tirebusiness.com
Financial incentives that employers provide to employees participating in wellness programs generally could not be included in determining if an employee is exempt from a healthcare reform law requirement to enroll in a plan offering minimum essential coverage under newly proposed regulations.
Healthcare plan premium contribution discounts are an example of such an incentive.
The Internal Revenue Service (IRS) regulations proposed Jan. 23 and published in the Jan. 27 Federal Register involve the relationship between a premium affordability test established by the Patient Protection and Affordability Act and the financial incentives employers provide for employees to participate in wellness programs.
Under the healthcare reform law, employees are required to enroll in a plan offering minimum essential coverage. If they do not, they are liable for a financial penalty. In 2014, the penalty is $95 or 1 percent of income, whichever is greater.
Employees are exempt from the penalty, however, if the premium their employer charges for coverage is “unaffordable,” which the law defines as greater than 8 percent of household income, and they did not enroll in the plan.
Under the proposed regulations, financial incentives, such as premium discounts for wellness program participation, would be excluded in running the 8 percent affordability test.
For example, if an employer charged employees a monthly premium of $100 for single coverage if they participated in a wellness program and $120 if they did not, the $120 premium assessment would be used to determine if the employee had access to affordable coverage.
In the case of premium discounts offered in connection with tobacco-cessation programs, however, the lower premium offered to employees participating in these programs would be used in running the premium affordability test, the IRS said.
“This rule is consistent with other Affordable Care Act provisions, such as one allowing insurers to charge higher premiums based on tobacco use,” the IRS said.
“There is more of a consensus among regulators on the benefits of tobacco-cessation programs compared with other wellness programs,” said Amy Bergner, managing director of human resources solutions at PricewaterhouseCoopers L.L.P. in Washington, referring to the different treatment for tobacco-cessation programs than other wellness programs.
This report appeared in Crain’s Business Insurance magazine, a Chicago-based sister publication of Tire Business.
Committee approves full-time worker bill
Originally posted February 04, 2014 by Allison Bell on https://www.benefitspro.com
Members of the House Ways and Means Committee today voted 23-14 to pass H.R. 2575, the Save American Workers Act bill.
For purposes of applying the Patient Protection and Affordable Care Act employer “shared responsibility” coverage mandate, the bill would define a full-time worker as an employee who works 40 hours or more per week.
PPACA now defines a full-time employee as an employee who works 30 or more hours per week.
PPACA requires employers that have the equivalent of 50 or more full-time employees to provide a minimum level of health coverage if one or more workers apply for coverage from a PPACA health insurance exchange.
Part-time workers count when employers are calculating the number of full-time equivalents they have, but employers subject to the PPACA “play or pay” mandate penalties tied to the number of actual full-time workers they have. When employers are calculating the actual penalty payment amounts, they can exclude part-time workers.
Rep. Todd Young, R-Ind., the sponsor, said the 30-hour limit is encouraging many employers to limit hours to avoid penalties.
“An employee seeing their hours cut from 39 hours to 29 hours will lose an entire week’s paycheck over the course of a month,” Young said.
Democrats on the committee said the bill would gut the coverage mandate by letting employers classify workers who work as many as 39 hours per week as part-time workers.
Rep. Xavier Becerra, D-Calif., noted that Ways and Means leaders gave the bipartisan Joint Committee on Taxation only a week to analyze the bill.
Budget analysts have not yet estimated how the bill might affect federal spending, taxes or the federal budget deficit, Becerra said.
“We’re essentially voting in the blind,” Becerra said.
Public Exchanges Competitive with Employer-Sponsored Plan
Originally posted January 30, 2014 by Michael Giardina on https://eba.benefitnews.com
Premiums for health plans on new state exchanges under the Affordable Care Act are comparable to – and in some cases lower than – those being offered by employers with similar levels of coverage, according to a study released Thursday by PricewaterhouseCooper’s Health Research Institute.
HRI analyzed the average premium costs for a working population nationally in the public exchanges, and calculated that the median 2014 premium for a plan with coverage similar to that of the average employer-sponsored plan was $5,844. By comparison, the average employer premium for a single worker was $6,119, a difference of 4%. The premiums do not include subsidies.
The ACA allows for consumers to shop on its 51 new state exchanges within four plan levels; these include bronze, which pays 60% of healthcare costs; silver, which covers 70%; gold, which covers 80%; and platinum, which covers 90% of the bill.
Currently, employer-sponsored health plans cover about 85% of healthcare costs, with the remaining costs being charged to employees, the PwC study states.
Across the board, at every level, average exchange premiums are lower than this year’s average premiums for employer-sponsored coverage, according to the data.
“Employers may be surprised that exchange premiums in 2014 are comparable to employer premiums and in some states significantly lower than employer-based premiums,” says the report. “Employers contemplating future limits to their health care spending could face less resistance if employees are given a wider range of options at different price points via an exchange.”
The report cautions, however, that future fluctuations in public exchange rates are possible because health plans are competing under a new set of underwriting rules which provide some protections against financial risk. “As a result of this uncertainty, the first-year exchange rates vary significantly. It may take several years for this new market to reach equilibrium,” it says.
HRI’s analysis is based data of employer-sponsored premiums of 156 million people in 2013. The analysis compares the premiums paid by employers for single worker coverage to premiums paid for similar coverage in the state exchanges.
Will Your Plan Cover Spouses?
Originally posted by Keith R. McMurdy on https://www.mondaq.com
I happened upon two interesting articles today about spousal coverage under employer sponsored benefit plans. The first was an article about UPS eliminating spousal coverage and blaming PPACA. The second was a study conducted by the Employee Benefits research Institute that concluded that, on average, spouses cost more to insure than employees, but elimination of spousal coverage may not save money in the long run. Without opining on whether or not the elimination of spousal coverage makes financial sense, there is an issue here about how to eliminate spouses from eligibility under a health plan which bears some consideration.
Generally, PPACA defines affordable coverage based on the single "employee only" rate. Employers are required to offer dependent coverage, but that requirement excludes an obligation to offer coverage for a spouse. So, like UPS, an employer can eliminate coverage for souses, keep coverage for children and still satisfy PPACA's requirements. But UPS did not eliminate all spouses from eligibility, only those with coverage available from their own employer. So if the decision is made to eliminate spousal coverage that is not necessarily the end of the process.
Will the coverage be offered to spouses who don't have other options or will all spouses be excluded? What are the definitions of dependent in the plan? Do you offer family coverage and not "single plus children" or "single plus spouse'? It comes down to the ongoing requirement to make your PPACA compliance plan meet the ERISA requirements. Remember that eligibility is dictated by plan terms and if your plan does not define terms like "spouse," "dependent" and "family," you could be creating a problem with ERISA by having conflicting interpretations of those terms. Then, assuming your definitions are complete, you have to make sure the eligibility rules you outlined not only use those definitions but also clearly explain the eligibility requirements. In the case of UPS, what does it mean to have "other available coverage"?
If you decide to offer coverage to spouses who don't have other coverage, how will you verify eligibility? What are your rules for confirming eligibility? How are these rules communicated? There are no absolute answers to these questions and employers have a variety of options for plan administration if they decided to go this route. But they have to think these things through in advance. Never lose sight of the fact that when an employer provides health insurance to employees, it is a plan sponsor under ERISA. Make sure that if you decide to restrict spousal coverage because of PPACA, you follow ERISA rules in the process.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
3 takeaways for employee benefits industry from Obama’s State of the Union address
Originally posted January 29, 2014 by Julie Stich on https://ebn.benefitnews.com
Following President Obama’s fifth State of the Union address, the International Foundation of Employee Benefit Plans closely examined the key takeaways that will affect the employee benefits industry.
No. 1: The Affordable Care Act is here to stay and opponents will face a difficult, if not impossible, task to repeal it legislatively. However, the door is still open to make changes and improvements to the existing law.
No. 2: The ACA still needs many more “young invincibles” to sign up in order to keep costs low for others.
No. 3: Apprenticeship and other job training programs are going to be a major focus for the administration in 2014. Led by Vice President Biden, these efforts will work to mobilize business leaders, community colleges, mayors and governors, and labor leaders to increase funding and the number of innovative apprenticeships in America.
Without a doubt, the Affordable Care Act has had the most significant impact on the employee benefits industry in decades and even though the president’s address maintained a light focus on the issue, it will continue to affect our industry and raise questions with the public and employers for the foreseeable future. In addition, the president’s announcement of a major initiative to support apprenticeship and other job training programs has the opportunity to provide our industry with many benefits and needed resources.
Another PPACA deadline delayed
Originally posted December 12, 2013 by Allison Bell on https://www.benefitspro.com
The Obama administration has issued new regs that public exchanges – and participating carriers – can use to cope with startup problems. Most importantly, it pushes the selection and payment deadline for Jan.1 plan coverage to Dec. 23.
The Centers for Medicare & Medicaid Services has given the batch of “interim final regulations” the title “Maximizing January 1, 2014, Coverage Opportunities” and is preparing to publish the regs in the Federal Register next week.
The Dec. 23 deadline applies to all sorts of exchange plans, including Small Business Health Options Program QHPs, multi-state plans and standalone dental pans, officials said. The original deadline was Dec. 15.
Insurers selling commercial plans through the exchanges with coverage dates starting Jan. 1 now must accept premium payments as late as Dec. 31.
State-based exchanges can set later deadlines for either individual or SHOP coverage.
Managers of state-based exchanges who want to offer more flexibility can push the payment deadline for coverage that starts Jan. 1 back to Jan. 31, “if a QHP issuer is willing to accept such enrollments,” officials said.
Officials also included rules for provider directories.
If a QHP issuer has trouble keeping its provider directory up to date, it should add consumer safeguards, such as using the version of a provider directory available to consumers in a given month to determine whether care from a provider will be classified as in-network care, officials said.
It was the second PPACA-related delay a day after HHS Secretary Kathleen Sebelius testified before Congress.
13 things employers must do to be PPACA-ready
Originally posted September 25, 2013 by Dan Cook on https://www.benefitspro.com
Uncertainty over the impact of health care reform on their businesses has created plenty of anxiety among HR managers and those in the C-Suite.
A recent survey by ADP found almost half of large-company finance managers aren’t fully confident that they understand their responsibilities under the Patient Protection and Affordable Care Act. At small companies, the study found, just 28 percent of those surveyed have developed any sort of plan for controlling their health benefits costs in the wake of health care reform. At large companies, that percent rose to 40 percent — still not very confidence-inspiring.
Executives know reform is going to rock their boat. When asked by ADP whether they thought the public insurance exchanges would have an impact on their company, half of small company respondents thought it would, while nearly 70 percent of large companies responded affirmatively.
To help employers get a better handle on the act’s requirements, ADP has come up with following recommendations for coping with health care reform.
EVALUATE
1. Know the requirements and deadlines:Don’t wallow in fears that are groundless with respect to your company. ADP says you should “invest the time and resources needed to clearly comprehend the act’s legal requirements and time frames in order to accommodate its tax implications and avoid penalties for non-compliance.” Establish a timeline with key milestones to help guide your process.
2. Determine administrative impact on your company: How will oversight of changes mandated by the PPACA increase administrative burden? “A prime example of an ACA provision with potentially large administrative impact is Shared Responsibility. Beginning in 2015, it requires tracking each employee’s full-time or part-time status every month, and maintaining that information as part of employee tax records.” Those kinds of requirements will clearly add to HR’s tasks, and may require additional manpower, at least while systems are being set up.
3. Calculate financial implications: There are myriad ways the mandated healthcare changes, reporting requirements, additional taxes, etc., will affect your cost of doing business. Coverage mandates for your benefits plan design, as well as reform-related taxes and fees, must all be taken into consideration. Over-budget for the short term at least.
EDUCATE
4. Create a written summary of benefits and coverage for employees: This is a four-page (or less) summary of your plan you must provide your employees with. It must be clearly written. Make sure you obtain acknowledgement of receipt of the SBC from employees.
5. Notify your employees of public exchanges: This is the notification of insurance options due Oct. 1. Is this required? Yes. Will you be fined if you don’t do it? Maybe not. Do it anyway. It’s a great way to communicate with your workers.
ENROLL
Sign ’em up: If you have at least 50 full-time employees, you have to offer them affordable health coverage. Make sure you offer the opportunity to enroll to all eligibles. Then develop a system to track, update and report on employee eligibility and enrollment to maintain ongoing compliance.
7. Enroll employees’ dependents: The law requires employers to offer coverage to qualifying dependent children of full-time employees up to age 26. You may also want to consider conducting a dependent eligibility audit, which typically show as many as 15 percent of dependents claimed by employees are not qualified for benefits.
8. Prepare for automatic enrollment: Employers with 200+ full-time employees will soon face new rules for enrolling new employees in the company’s group health plan. If you haven’t already, you’ll need to start thinking about solutions to address this requirement.
9. Assess your exchange/coverage options: Employers will generally choose from three different plan approaches for covering their employees – employer-sponsored plans, private exchanges and the new public exchanges created under the act. You’ll need to determine which works best for you, from both a financial and employee recruiting/retention standpoint.
EXECUTE
10 Get ready to define and track full-time and part-time employees: The act requires this tracking — it’s the basis for many calculations that are coming down the pike. Start tracking now so you won’t have to go back and try to recreate the data later.
11. Offer an employee wellness program: An earlier ADP study showed wellness programs are an increasingly popular strategy for offsetting the expense of healthcare – without passing on additional costs to employees.
12. Get a grip on your medical loss ratio rebates: These are sent to employers from their insurance carrier whenever health insurers do not spend at least a certain percentage of the prior year’s health insurance premiums on healthcare services. If you receive MLR rebate dollars, the plan must make a fiduciary decision about using the dough. A best practice is to communicate to your employees your intention as to how the MLR rebate will be used.
13. Limit employee flexible spending accounts (FSAs): Prior to the enactment of the act, the IRS permitted employers to determine the maximum amount an employee could set aside tax-free in a Flexible Spending Account. Going forward, you will need to enforce a $2,500 annual limit on all employee healthcare FSA contributions.
Employers up estimated costs of health care reform law
Original article from https://www.businessinsurance.com
By Jerry Geisel
Employers are upping their estimates of how much the health care reform law will increase costs, according to a Mercer L.L.C. survey released June 12.
Two years ago, 25% of employers thought that complying with the Patient Protection and Affordable Care Act would increase their health care plan costs by less than 1%. But now, just 9% of nearly 900 employers surveyed by Mercer expect a cost increase that small.
Similarly, 15% of employers in 2011 expected the health care reform law to increase costs by at least 5%. Now, 19% of employers expect cost increases of at least 5%. In addition, 21% are projecting 2014 health care reform law related cost increases of 1% to 2%, while 18% expect cost increases of 3% to 4%; 32% of respondents said they didn't know the cost impact.
Mercer executives said there are several reasons why more employers are increasing their cost estimates.
“As employers get closer to implementation, they have a better idea of how many additional employees will become eligible for coverage. Some that thought they would cut hours have changed their position on that,” Beth Umland, Mercer's director of research for health and benefits in New York, said in an email.
Under PPACA, employers will be liable for a $2,000-per-employee penalty if they do not provide coverage starting next year to full-time employees, or those working an average of 30 hours a week.
In addition, Ms. Umland said, some employers in 2011 didn't know about the various fees that the health care reform law imposes. For example, employers will have to pay a fee of $63 per health care plan participant in 2014 to fund a program that will partially reimburse health insurers for providing coverage to high-cost individuals. While there was some awareness of the Transitional Reinsurance Program, it wasn't until last year that regulators announced the size of the fee employers would have to pay.
Check out our HCR Central for FREE PPACA Downloads, FAQ's, and compliance news to help you and your company prepare for PPACA requirements that take effect later this year and in 2014.
Health Care Law Remains Deeply Divisive
Original article from https://triblive.com
By Dayton Daily News
David Peabody is apprehensive about the new health care law. Ericka Haverkos is hopeful about it.
These Ohio residents — one the owner of a small landscaping business in Columbus and the other a college student who works part time as a cashier — are emblematic of millions of Americans who next year will have to adapt to the most sweeping changes in the delivery of health care since the establishment of Medicare and Medicaid in 1965.
To Peabody, the law will impose steep costs on his company and force him to decide whether to insure his 65 workers or pay a fine to the federal government. To Haverkos, who says she has a learning disability, it could mean access to a doctor who could prescribe the medication she needs.
All across the nation, millions of people are facing the reality of a new era in health care. Signed into law in 2010 by President Obama and known as the Affordable Care Act, the law will extend health care coverage to more than 20 million of the 47 million Americans without insurance.
“For people who haven't been able to find affordable insurance, they are going to love it,” said Elise Gould, a health insurance analyst at the Economic Policy Institute, a left-leaning nonprofit organization in Washington.
The law's critics contend it's going to frustrate Americans with its complexities, new regulations and blizzard of fees and taxes that they claim will deal a major blow to a fragile economy still recovering from the 2008 financial crash.
When asked to describe how efficiently the law is being implemented, Thomas Miller, a health policy analyst at the conservative oriented American Enterprise Institute in Washington joked: “Coming along just fine. Steady as she goes right into the cliff. Don't mind that iceberg. The Titanic got past it.”
A Kaiser Family Foundation survey in April found that 49 percent of Americans lack the information to understand how the law works. More alarming to the Obama administration, a recent Wall Street Journal/NBC News poll showed that 49 percent of Americans believe the law is a bad idea while just 37 percent call it a good one.
The law extends coverage in two ways. It expands the eligibility for Medicaid, which provides health coverage to low-income people. For those making too much money to qualify for Medicaid, the law offers federal subsidies for families of four earning $33,000 to $94,000 a year so that they can buy their plans through exchanges operated by the federal government or their state.
“I do believe folks underestimated the enormity of this law,” said Kevin Kuhlman, a Washington lobbyist for the National Federation of Independent Businesses. “In order for it to be a success, not only does the government have a massive project ahead of it managing and operating these exchanges, but private businesses also will have to come along and make a lot of drastic changes.”
Haverkos, a student at the Columbus College of Art and Design, said she lost her health insurance more than two years ago when her mother's term on the state Board of Education ended. The health law lets adult children remain on their parents' health plan until age 26, but Haverkos said that's not an option for her.
She said her employer doesn't offer insurance to part-time employees like her. She said she has emergency coverage through the college. Under the law, her insurance through the college will be upgraded if she remains enrolled there.
Supporters of the health care law say people like Haverkos can get access to coverage because government subsidies make the coverage more affordable. Comprehensive coverage would help relieve the symptoms of her persistent allergies and, she said, give her security - a sense of comfort knowing that it's there.”
For some people, the subsidies would amount to considerable savings. According to the Kaiser Family Foundation, a single 45-year-old earning $28,735 a year would pay $5,733 a year in premiums under a typical plan. Using the ACA's graduated scale, which calls for more subsidies for lower-income people, that person would have $3,420 of the premium paid for by the government.
“Those people who have found it very difficult to have access to coverage will find it a good deal,” said Kenneth Thorpe, a one-time senior health official under former President Bill Clinton.
Others are scrambling to determine what the law will cost them.
Many small companies that have not been offering insurance will have to under the new law. That will force some into a choice between providing insurance for their workers or paying thousands of dollars in federal taxes.
The ACA will require a company with 50 or more full-time workers to provide insurance or pay a $2,000 per-person fine for every uninsured worker. The only exception is the first 30 workers in the company are excluded from the fine.
Peabody, who years ago took pride in covering the entire cost of his employees' health coverage, said he now has to calculate what he can afford.
Last year, his company paid $48,000 of the $119,000 in premiums charged by his insurer, with the workers picking up the rest.
Not all of his workers accept the company-provided insurance, Peabody said.
“A lot of people can't afford health insurance,” he said. “That's why they choose not to take it.”
Other businesses are facing similar choices. Jamie Richardson, vice president of White Castle, which has 406 hamburger shops across the country, said his company spent $36 million last year on health coverage for its 5,000 full-time workers. All told, the chain employs about 10,000 people.
Under the new law, White Castle must offer its full-time workers (or anyone working 30 hours or more a week) insurance within 90 days of their hire date. That's a change from current White Castle policy, which offers health insurance to workers six months after they are hired. The company could reduce the number of hours for some workers — as a few companies have said they would do — but the chain said it does not want to do that.
“If someone's full time, we want them to stay full time,” Richardson said. “We don't want people to lose benefits.” He did say the additional costs could mean fewer people are hired.
Opponents argue that adding 20 million into the health care system along with requirements for minimum federal coverage is likely to cause premiums to rise for everyone insured in the United States. By contrast, supporters say the new law will restrain the growth rate of health care because insured people will not be flooding emergency rooms for care.
Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation, said the true costs of the new law will be difficult to calculate.
“For most people with employer-sponsored coverage, the cost of that coverage has been increasing over the past decade,” she said. Determining how much of those costs are due to general trends as opposed to the new law will be “hard to disentangle.”
The Hundred Years’ War for Healthcare Reform
Original article from https://inthesetimes.com
By A.W. Gaffney
The story of healthcare reform in the United states begins not with Obama, Clinton or even Johnson, but almost a century ago, in the years leading up to World War I. Although the Socialist Party of America had called for insurance for workers “against accident, sickness and lack of employment” as early as 1904, it wasn’t until 1912, when the platform of Theodore Roosevelt’s Progressive Party called for a system of health insurance, that it emerged as a major political issue. Roosevelt lost the election, but progressives were nonetheless optimistic that healthcare legislation could be passed at the state level, and in 1916, progressive state legislators submitted “compulsory” health insurance bills to the legislatures of New York, Massachusetts and New Jersey. Much like the “employer mandate” of the Affordable Care Act, these plans would have required industrial employers to contribute to medical coverage and sick pay for workers and their families.
These were bold ideas, but they met with unfortunate timing, as two developments in Europe furnished powerful ideological weapons to those who opposed the legislation: in April 1917, the United states entered the war against Germany, and the following October, the Bolsheviks seized power in Moscow.
These global events proved politically useful to physicians in the American Medical Association (AMA), who had come to see health insurance legislation as a threat to both their independence and income. The AMA could now paint state-based health insurance as both pro-German (given its roots in Otto von Bismarck’s 19th-century social insurance) and pro-Bolshevik. Though the former claim had far more basis in fact, the latter smear was to prove the more enduring—throughout the healthcare reform debate of 2009-2010, even the most moderate of reform proposals were lambasted as communist by the Right. The effect in 1918 was a turning of the tide against the promising state plans that ended in their total defeat and decades of inaction.
For the next 90-odd years, efforts at sweeping healthcare reform in the United States were a series of failures. New Dealers picked up healthcare reform again in the 1930s, seeking to weave it into the new social safety net. However, fear of the physician lobby—which had flexed its newfound political muscle so effectively in the state-based campaigns of 1916-1918—encouraged Franklin D. Roosevelt to leave health insurance out of his landmark Social Security Act. Still, over time, Roosevelt leaned toward a system of universal healthcare, arguing in his famous 1944 “Second Bill of Rights” State of the Union Address for the “right to adequate medical care and the opportunity to achieve and enjoy good health.”
Though Roosevelt died the following year, the New Deal conception of universal healthcare lived on in the series of “Wagner-Murray-Dingell” (WMD) health bills of the Truman years. In its 1945 version, the WMD bill would have established universal national health insurance based on the European model. The AMA, still opposed to reform, again won the old-fashioned way, by red-baiting WMD to its grave.
Branding the bill with the hammer and sickle turned the fight over universal healthcare into yet another front of the developing Cold War, so much so that when the Johnson administration again sought to remake American healthcare in the 1960s, it strategically pursued reforms only for those individuals who were the least able to afford medical care and therefore the most politically inoffensive: the poor and the elderly. Thus Medicare and Medicaid were born.
Subsequent decades saw a number of universal healthcare proposals crash and burn: Ted Kennedy’s “health security” plan in 1970, Nixon’s plan in 1974, and Clinton’s in 1993.
This series of missteps and lost opportunities gives a sense of the stakes when the healthcare debate again took center stage after the election of Obama in 2008. But Obama also had to contend with a corporate healthcare industry that had grown enormously in power and influence in the hundred years between the WWI-era campaigns and his first term. Indeed, the relatively crude public relations campaign of the AMA in the 1910s was nothing compared to the massive lobbying machines of the insurance and pharmaceutical industries in the 21st century. These corporate “stakeholders” were to critically influence the terms of the healthcare reform debate of 2009-2010.
For instance, the health insurance lobby agreed to support the elimination of “pre-existing” conditions in exchange for a number of industry-favorable provisions, such as an individual mandate. Similarly, the pharmaceutical lobby agreed to support reform legislation so long as it did not allow Medicare to negotiate directly with pharmaceutical companies over drug prices, areform that by one estimate could have saved the government between $230 billion and $541 billion over ten years. And there’s no doubt that industry influences limited reform in other, less obvious ways, whether it was the early exclusion a single-payer system or the elimination of a “public option” from the final bill.
But clearly, these various, intertwined historical dynamics—stretching back 100 years—contributed crucially to the final form of the landmark legislation that lay upon Obama’s desk on March 23, 2010.