title: Affordable Care Act

text: The Senate began work on its own proposals while the House was still working. The United States Constitution requires all revenue-related bills to originate in the House. To formally comply with this requirement, the Senate repurposed H.R. 3590, a bill regarding housing tax changes for service members. It had been passed by the House as a revenue-related modification to the Internal Revenue Code. The bill became the Senate's vehicle for its healthcare reform proposal, discarding the bill's original content. The bill ultimately incorporated elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican Senate minority vowing to filibuster, 60 votes would be necessary to pass the Senate. At the start of the 111th Congress, Democrats had 58 votes. The Minnesota Senate election was ultimately won by Democrat Al Franken, making 59. Arlen Specter switched to the Democratic party in April 2009, giving them 60 seats, enough to end a filibuster.


title: Affordable Care Act

text: Negotiations were undertaken attempting to satisfy moderate Democrats and to bring Republican senators aboard; particular attention was given to Republicans Bennett, Enzi, Grassley and Snowe.


title: Affordable Care Act

text: After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Senate Majority Leader Harry Reid focused on satisfying centrists. The holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat Ben Nelson. Lieberman's demand that the bill not include a public option was met, although supporters won various concessions, including allowing state-based public options such as Vermont's failed Green Mountain Care.


title: Affordable Care Act

text: The White House and Reid addressed Nelson's concerns during a 13-hour negotiation with two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges", which would require consumers to pay for the procedure out of pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska. The latter half of the compromise was derisively termed the "Cornhusker Kickback" and was later removed.


title: Affordable Care Act

text: On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster. The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except Jim Bunning, who did not vote). The bill was endorsed by the American Medical Association and AARP.


title: Affordable Care Act

text: On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the recently deceased Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters. Additionally, the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of the bill.


title: Affordable Care Act

text: With Democrats no longer able to get the 60 votes to break a filibuster in the Senate, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill, but House Speaker Nancy Pelosi pushed back, dismissing more moderate reform as "Kiddie Care".


title: Affordable Care Act

text: Obama remained insistent on comprehensive reform. The news that Anthem in California intended to raise premium rates for its patients by as much as 39% gave him new evidence of the need for reform. On February 22, he laid out a "Senate-leaning" proposal to consolidate the bills. He held a meeting with both parties' leaders on February 25. The Democrats decided the House would pass the Senate's bill, to avoid another Senate vote.


title: Affordable Care Act

text: House Democrats had expected to be able to negotiate changes in a House–Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill. They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.


title: Affordable Care Act

text: Per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations. Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."


title: Affordable Care Act

text: The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their concerns, but they could not address abortion in the reconciliation bill as it would be non-budgetary. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. This won the support of Stupak and members of his group and assured the bill's passage. The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. It passed the second bill, by 220–211, the same day (with the Senate passing this bill via reconciliation by 56-43 a few days later). The day after the passage of ACA, March 22, Republicans introduced legislation to repeal it. Obama signed ACA into law on March 23, 2010.


title: Affordable Care Act

text: Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act more than sixty times.


title: Affordable Care Act

text: The Tax Cuts and Jobs Act of 2017 eliminated the fine for violating the individual mandate, starting in 2019. (The requirement itself is still in effect.) In 2019 Congress repealed the so-called "Cadillac" tax on health insurance benefits, an excise tax on medical devices, and the Health Insurance Tax.


title: Affordable Care Act

text: The American Rescue Plan Act of 2021, enacted during the COVID-19 pandemic in the United States, expanded subsidies for marketplace health plans. A continuation of these subsidies was introduced as part of the Inflation Reduction Act of 2022.


title: Affordable Care Act

text: The law caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% from January to June 2016. The uninsured rate dropped in every congressional district in the U.S. from 2013 to 2015. The Congressional Budget Office reported in March 2016 that approximately 12 million people were covered by the exchanges (10 million of whom received subsidies) and 11 million added to Medicaid. Another million were covered by ACA's "Basic Health Program", for a total of 24 million. CBO estimated that ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4million for reductions in "employment-based coverage" and "non-group and other coverage".


title: Affordable Care Act

text: The U.S. Department of Health and Human Services (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016; similarly, the Urban Institute found in 2016 that 19.2 million non-elderly Americans gained health insurance coverage from 2010 to 2015. In 2016, CBO estimated the uninsured at approximately 27 million people, or around 10% of the population or 7–8% excluding unauthorized immigrants.


title: Affordable Care Act

text: States that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not had a 14.1% uninsured rate, among adults aged 18–64. As of December 2016 32 states (including Washington DC) had adopted the Medicaid extension.


title: Affordable Care Act

text: The Affordable Care Act reduced the percent of Americans between 18 and 64 who were uninsured from 22.3 percent in 2010 to 12.4 percent in 2016. About 21 million more people have coverage ten years after the enactment of the ACA. Ten years after its enactment studies showed that the ACA also had a positive effect on health and caused a reduction in mortality.


title: Affordable Care Act

text: Excise taxes from the Affordable Care Act raised $16.3 billion in fiscal year 2015. $11.3 billion came from an excise tax placed directly on health insurers based on their market share. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs.


title: Affordable Care Act

text: The Individual mandate tax was $695 per individual or $2,085 per family at a minimum, reaching as high as 2.5% of household income (whichever was higher). The tax was reduced to 0 at the end of 2018.


title: Affordable Care Act

text: In fiscal year 2018, the individual and employer mandates yielded $4 billion each. Excise taxes on insurers and drug makers added $18 billion. Income tax surcharges produced 437 billion.


title: Affordable Care Act

text: ACA reduced income inequality measured after taxes, due to the income tax surcharges and subsidies. CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. The tax subsidy for the employer market, was approximately $1,700 per person in 2016, or $266 billion total.


title: Affordable Care Act

text: As of August 2016, 15 states operated their own health insurance marketplace. Other states either used the federal exchange, or operated in partnership with or supported by the federal government. By 2019, 12 states and Washington DC operated their own exchanges.


title: Affordable Care Act

text: As of December 2019, 37 states (including Washington DC) had adopted the Medicaid extension. Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while the others had a 14.1% uninsured rate, among adults aged 18 to 64. Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they did not expand Medicaid under ACA, several states rejected the option. Over half the national uninsured population lived in those states.


title: Affordable Care Act

text: The Centers for Medicare and Medicaid Services (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9to 10 million people had gained Medicaid coverage, mostly low-income adults. The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered because of states that rejected the Medicaid expansion.


title: Affordable Care Act

text: In many states income thresholds were significantly below 133% of the poverty line. Many states did not make Medicaid available to childless adults at any income level. Because subsidies on exchange insurance plans were not available to those below the poverty line, such individuals had no new options. For example, in Kansas, where only non-disabled adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance. Absent children, non-disabled adults were not eligible for Medicaid there.


title: Affordable Care Act

text: Studies of the impact of Medicaid expansion rejections calculated that up to 6.4 million people would have too much income for Medicaid but not qualify for exchange subsidies. Several states argued that they could not afford the 10% contribution in 2020. Some studies suggested rejecting the expansion would cost more due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,


title: Affordable Care Act

text: A 2016 study found that residents of Kentucky and Arkansas, which both expanded Medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period. Kentucky opted for increased managed care, while Arkansas subsidized private insurance. Later Arkansas and Kentucky governors proposed reducing or modifying their programs. From 2013 to 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas.


title: Affordable Care Act

text: A 2016 DHHS study found that states that expanded Medicaid had lower premiums on exchange policies, because they had fewer low-income enrollees, whose health on average is worse than that of those with higher income.


title: Affordable Care Act

text: In September 2019, the Census Bureau reported that states that expanded Medicaid under the ACA had considerably lower uninsured rates than states that did not. For example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid. The drop in uninsured rates due to expanded Medicaid has broadened access to care among low-income adults, with post-ACA studies indicating an improvement in affordability, access to doctors, and usual sources of care.


title: Affordable Care Act

text: A study using national data from the Health Reform Monitoring Survey determined that unmet need due to cost and inability to pay medical bills significantly decreased among low-income (up to 138% FPL) and moderate-income (139-199% FPL) adults, with unmet need due to cost decreasing by approximately 11 percentage points among low-income adults by the second enrollment period. Importantly, issues with cost-related unmet medical needs, skipped medications, paying medical bills, and annual out-of-pocket spending have been significantly reduced among low-income adults in Medicaid expansion states compared to non-expansion states.


title: Affordable Care Act

text: As well, expanded Medicaid has led to a 6.6% increase in physician visits by low-income adults, as well as increased usage of preventative care such as dental visits and cancer screenings among childless, low-income adults. Improved health care coverage due to Medicaid expansion has been found in a variety of patient populations, such as adults with mental and substance use disorders, trauma patients, cancer patients, and people living with HIV. Compared to 2011–13, in 2014 there was a 5.4 percentage point reduction in the uninsured rate of adults with mental disorders (from 21.3% to 15.9%) and a 5.1 percentage point reduction in the uninsured rate of adults with substance use disorders (from 25.9% to 20.8%); with increases in coverage occurring primarily through Medicaid. Use of mental health treatment increased by 2.1 percentage points, from 43% to 45.1%.


title: Affordable Care Act

text: Among trauma patients nationwide, the uninsured rate has decreased by approximately 50%. Adult trauma patients in expansion states experienced a 13.7 percentage point reduction in uninsured rates compared to adult trauma patients in non-expansion states, and an accompanying 7.4 percentage point increase in discharge to rehabilitation. Following Medicaid expansion and dependent coverage expansion, young adults hospitalized for acute traumatic injury in Maryland experienced a 60% increase in rehabilitation, 25% reduction in mortality, and a 29.8% reduction in failure-to-rescue. Medicaid expansion's swift impact on cancer patients was demonstrated in a study using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that evaluated more than 850,000 patients diagnosed with breast, lung, colorectal, prostate cancer, or thyroid cancer from 2010 to 2014. The study found that a cancer diagnosis in 2014 was associated with a 1.9 percentage-point absolute and 33.5% relative decrease in uninsured rates compared to a diagnosis made between 2010 and 2013. Another study, using Surveillance, Epidemiology, and End Results (SEER) Program data from 2010 to 2014, found that Medicaid expansion was associated with a 6.4% net increase in early stage (in situ, local, or regional) diagnoses of all cancers combined.


title: Affordable Care Act

text: Data from the Centers for Disease and Prevention's (CDC) Medical Monitoring Project demonstrated that between 2009 and 2012, approximately 18% of people living with HIV (PLWH) who were actively receiving HIV treatment were uninsured and that at least 40% of HIV-infected adults receiving treatment were insured through Medicaid and/or Medicare, programs they qualified for only once their disease was advanced enough to be covered as a disability under Social Security. Expanded Medicaid coverage of PLWH has been positively associated with health outcomes such as viral suppression, retention of care, hospitalization rates, and morbidity at the time of hospitalization. An analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data found a 2.8% annual increase in viral suppression rates among all PLWH from 2010 to 2015 due to Medicaid expansion. In Nebraska, PLWH newly covered by Medicaid expansion in 2013-14 were four times more likely to be virally suppressed than PLWH who were eligible but remained uninsured. As an early adopter of Medicaid expansion, Massachusetts found a 65% rate of viral suppression among all PLWH and an 85% rate among those retained in healthcare in 2014, both substantially higher than the national average.


title: Affordable Care Act

text: An analysis of hospital discharge data from 2012 to 2014 in four Medicaid expansion states and two non-expansion states revealed hospitalizations of uninsured PLWH fell from 13.7% to 5.5% in the four expansion states and rose from 14.5% to 15.7% in the two non-expansion states. Importantly, uninsured PLWH were 40% more likely to die in the hospital than insured PLWH. Other notable health outcomes associated with Medicaid expansion include improved glucose monitoring rates for patients with diabetes, better hypertension control, and reduced rates of major post-operative morbidity.


title: Affordable Care Act

text: A July 2019 study by the National Bureau of Economic Research (NBER) indicated that states enacting Medicaid expansion exhibited statistically significant reductions in mortality rates. From that study, states that took Medicaid expansion "saved the lives of at least 19,200 adults aged 55 to 64 over the four-year period from 2014 to 2017." Further, 15,600 older adults died prematurely in the states that did not enact Medicaid expansion in those years according to the NBER research. "The lifesaving impacts of Medicaid expansion are large: an estimated 39 to 64 percent reduction in annual mortality rates for older adults gaining coverage."


title: Affordable Care Act

text: Due to many states' failure to expand, many Democrats co-sponsored the proposed 2021 Cover Now Act that would allow county and municipal governments to fund Medicaid expansion.


title: Affordable Care Act

text: National health care expenditures rose faster than national income both before (2009-2013: 3.73%) and after (2014-2018: 4.82%) ACA's major provisions took effect. Premium prices rose considerably before and after. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas. However, some or all these costs were offset by tax credits. For example, the Kaiser Family Foundation reported that for the second-lowest cost "Silver plan", a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the tax credit, despite a large increase in the list price. This was consistent nationally. In other words, the subsidies increased along with the premium price, fully offsetting the increases for subsidy-eligible enrollees.


title: Affordable Care Act

text: Premium cost increases in the employer market moderated after 2009. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015, with only a 3% increase from 2015 to 2016. From 2008 to 2010 (before passage of ACA) health insurance premiums rose by an average of 10% per year.


title: Affordable Care Act

text: Several studies found that the financial crisis and accompanying recession could not account for the entirety of the slowdown and that structural changes likely shared at least partial credit. A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation. Paul Krawzak claimed that even if cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly the growth of the population on Medicare.


title: Affordable Care Act

text: In a 2016 review, Barack Obama claimed that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.


title: Affordable Care Act

text: A contributing factor to premium cost moderation was that the insured faced higher deductibles, copayments and out-of-pocket maximums. In addition, many employees chose to combine a health savings account with higher deductible plans, making the net impact of ACA difficult to determine precisely.


title: Affordable Care Act

text: For the non-group market, of which two-thirds are covered by ACA exchanges, a survey of 2015 data found that:


title: Affordable Care Act

text: According to a 2014 study, ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013. Himmelstein and Woolhandler wrote in January 2017 that a rollback of ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.


title: Affordable Care Act

text: According to the Kaiser Foundation, expanding Medicaid in the remaining states would cover up to 4.5 million persons. A 2021 study found a significant decline in mortality rates in the states that opted in to the Medicaid expansion program compared with those states that did not do so. The study reported that states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017.


title: Affordable Care Act

text: Dependent Coverage Expansion (DCE) under the ACA has had a demonstrable effect on various health metrics of young adults, a group with a historically low level of insurance coverage and utilization of care. Numerous studies have shown the target age group gained private health insurance relative to an older group after the policy was implemented, with an accompanying improvement in having a usual source of care, reduction in out-of-pocket costs of high-end medical expenditures, reduction in frequency of Emergency Department visits, 3.5% increase in hospitalizations and 9% increase in hospitalizations with a psychiatric diagnosis, 5.3% increase in utilizing specialty mental health care by those with a probable mental illness, 4% increase in reporting excellent mental health, and a 1.5-6.2% increase in reporting excellent physical health. Studies have also found that DCE was associated with improvements in cancer prevention, detection, and treatment among young adult patients. A study of 10,010 women aged 18–26 identified through the 2008-12 National Health Interview Survey found that the likelihood of HPV vaccination initiation and completion increased by 7.7 and 5.8 percentage points respectively when comparing before and after October 1, 2010. Another study using National Cancer Database (NCDB) data from 2007 to 2012 found a 5.5 percentage point decrease in late-stage (stages III/IV) cervical cancer diagnosis for women aged 21–25 after DCE, and an overall decrease of 7.3 percentage points in late-stage diagnosis compared to those aged 26–34. A study using SEER Program data from 2007 to 2012 found a 2.7 percentage point increase in diagnosis at stage I disease for patients aged 19–25 compared with those aged 26–34 for all cancers combined. Studies focusing on cancer treatment after DCE found a 12.8 percentage point increase in the receipt of fertility-sparing treatment among cervical cancer patients aged 21–25 and an overall increase of 13.4 percentage points compared to those aged 26–34, as well as an increased likelihood that patients aged 19–25 with stage IIB-IIIC colorectal cancer receive timely adjuvant chemotherapy compared to those aged 27–34.


title: Affordable Care Act

text: Two 2018 "JAMA" studies found the Hospital Readmissions Reduction Program (HRRP) was associated with increased post-discharge mortality for patients hospitalized for heart failure and pneumonia. A 2019 "JAMA" study found that ACA decreased emergency department and hospital use by uninsured individuals. Several studies have indicated that increased 30-day, 90-day, and 1-year post-discharge mortality of heart failure patients can be attributed to "gaming the system" through inappropriate triage systems in emergency departments, use of observation stays when admissions are warranted, and delay of readmission beyond the 30th day post-discharge, strategies that can reduce readmission rates at the expense of quality of care and patient survival. The HRRP was also shown to disproportionately penalize safety-net hospitals that predominately serve low-income patients. A 2020 study by Treasury Department economists in the "Quarterly Journal of Economics" using a randomized controlled trial (the IRS sent letters to some taxpayers noting that they had paid a fine for not signing up for health insurance but not to other taxpayers) found that over two years, obtaining health insurance reduced mortality by 12 percent. The study concluded that the letters, sent to 3.9 million people, may have saved 700 lives.


title: Affordable Care Act

text: A 2020 "JAMA" study found that Medicare expansion under the ACA was associated with reduced incidence of advanced-stage breast cancer, indicating that Medicaid accessibility led to early detection of breast cancer and higher survival rates. Recent studies have also attributed to Medicaid expansion an increase in use of smoking cessation medications, cervical cancer screening, and colonoscopy, as well as an increase in the percentage of early-stage diagnosis of all cancers and the rate of cancer surgery for low-income patients. These studies include a 2.1% increase in the probability of smoking cessation in Medicaid expansion states compared to non-expansion states, a 24% increase in smoking cessation medication use due to increased Medicaid-financed smoking cessation prescriptions, a 27.7% increase in the rate of colorectal cancer screening in Kentucky following Medicaid expansion with an accompanying improvement in colorectal cancer survival, and a 3.4% increase in cancer incidence following Medicaid expansion that was attributed to an increase in early-stage diagnoses.


title: Affordable Care Act

text: Transition-of-care interventions and Alternative Payment Models under the ACA have also shown promise in improving health outcomes. Post-discharge provider appointment and telephone follow-up interventions have been shown to reduce 30-day readmission rates among general medical-surgical inpatients. Reductions in 60, 90, and 180 post-discharge day readmission rates due to transition-of-care interventions have also been demonstrated, and a reduction in 30-day mortality has been suggested. Total joint arthroplasty bundles as part of the Bundled Payments for Care Improvement initiative have been shown to reduce discharge to inpatient rehabilitation facilities and post-acute care facilities, decrease hospital length of stay by 18% without sacrificing quality of care, and reduce the rate of total joint arthroplasty readmissions, half of which were due to surgical complications. The Hospital Value-Based Purchasing Program in Medicaid has also shown the potential to improve health outcomes, with early studies reporting positive and significant effects on total patient experience score, 30-day readmission rates, incidences of pneumonia and pressure ulcers, and 30-day mortality rates for pneumonia. The patient-centered medical home (PCMH) payment and care model, a team-based approach to population health management that risk-stratifies patients and provides focused care management and outreach to high-risk patients, has been shown to improve diabetes outcomes. A widespread PCMH demonstration program focusing on diabetes, known as the Chronic Care Initiative in the Commonwealth of Pennsylvania, found statistically significant improvements in A1C testing, LDL-C testing, nephropathy screening and monitoring, and eye examinations, with an accompanying reduction in all-cause emergency department visits, ambulatory care-sensitive emergency department visits, ambulatory visits to specialists, and a higher rate of ambulatory visits to primary care providers. The ACA overall has improved coverage and care of diabetes, with a significant portion of the 3.5 million uninsured US adults aged 18–64 with diabetes in 2009-10 likely gaining coverage and benefits such as closure of the Medicaid Part D coverage gap for insulin. 2.3 million of the approximately 4.6 million people aged 18–64 with undiagnosed diabetes in 2009-2010 may also have gained access to zero-cost preventative care due to section 2713 of the ACA, which prohibits cost sharing for United States Preventive Services Taskforce grade A or B recommended services, such as diabetes screenings.


title: Affordable Care Act

text: In March 2018, the CBO reported that ACA had reduced income inequality in 2014, saying the law led the lowest and second quintiles (the bottom 40%) to receive an average of an additional $690 and $560 respectively while causing households in the top 1% to pay an additional $21,000 due mostly to the net investment income tax and the additional Medicare tax. The law placed relatively little burden on households in the top quintile (top 20%) outside of the top 1%.


title: Affordable Care Act

text: The CBO reported in multiple studies that ACA would reduce the deficit, and repealing it would increase the deficit, primarily because of the elimination of Medicare reimbursement cuts. The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period: it calculated the law would result in $604 billion in total outlays offset by $813 billion in total receipts, resulting in a $210 billion net deficit reduction. The CBO separately predicted that while most of the spending provisions do not begin until 2014, revenue would exceed spending in those subsequent years. The CBO claimed the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs"—ultimately extending the solvency of the Medicare trust fund by eight years.


title: Affordable Care Act

text: This estimate was made prior to the Supreme Court's ruling that enabled states to opt out of the Medicaid expansion, thereby forgoing the related federal funding. The CBO and JCT subsequently updated the budget projection, estimating the impact of the ruling would reduce the cost estimate of the insurance coverage provisions by $84 billion.


title: Affordable Care Act

text: The CBO in June 2015 forecast that repeal of ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic feedback effects. The CBO also forecast that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2025, mainly by boosting the supply of labor.


title: Affordable Care Act

text: Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion. CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".


title: Affordable Care Act

text: In 2017 CBO estimated that repealing the individual mandate alone would reduce the 10-year deficit by $338 billion.


title: Affordable Care Act

text: The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019. However, the so-called "doc fix" is a separate issue that would have existed with or without ACA. The Center on Budget and Policy Priorities objected that Congress had a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings, although not the doc fix. The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.


title: Affordable Care Act

text: Health economist Uwe Reinhardt, wrote, "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation." Douglas Holtz-Eakin alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.


title: Affordable Care Act

text: Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from preventive healthcare, and that the CBO had a track record of overestimating costs and underestimating savings of health legislation; stating, "innovations in the delivery of medical care, like greater use of electronic medical records and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another—and that meant there wasn't much hard data to prove the savings would materialize."


title: Affordable Care Act

text: In 2010 David Walker said the CBO estimates were not likely to be accurate, because they were based on the assumption that the law would not change.


title: Affordable Care Act

text: The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers. Critics claimed it created a perverse incentive to hire part-timers instead. However, between March 2010 and 2014, the number of part-time jobs declined by 230,000 while the number of full-time jobs increased by two million. In the public sector full-time jobs turned into part-time jobs much more than in the private sector. A 2016 study found only limited evidence that ACA had increased part-time employment.


title: Affordable Care Act

text: Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees, to reflect the 30-hour-or-more definition for full-time worker. As of 2013, few companies had shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis). Trends in working hours and the recovery from the Great Recession correlate with the shift from part-time to full-time work. Other confounding impacts include that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and lowers corresponding training and administration costs from a smaller, more stable workforce. Relatively few firms employ over 50 employees and more than 90% of them already offered insurance.


title: Affordable Care Act

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


title: Affordable Care Act

text: From the start of 2010 to November 2014, 43 hospitals in rural areas closed. Critics claimed the new law had caused these closures. Many rural hospitals were built using funds from the 1946 Hill–Burton Act. Some of these hospitals reopened as other medical facilities, but only a small number operated emergency rooms (ER) or urgent care centers.


title: Affordable Care Act

text: Between January 2010 and 2015, a quarter of ER doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured. Michael Lee, Jr. and Michael C. Monuteaux at Boston Children's Hospital analyzed national emergency department visits among children aged 0 to 17 from 2009 to 2016 using the American Community Survey (ACS) and Nationwide Emergency Department Sample (NEDS). They found no immediate change in pediatric emergency department visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends, almost 10%.


title: Affordable Care Act

text: Several large insurers formed ACOs. Many hospitals merged and purchased physician practices, amounting to a significant consolidation of the provider industry. The increased market share gave them more leverage with insurers and reduced patient care options.


title: Affordable Care Act

text: In 2015 the progressive Center for Economic and Policy Research found no evidence that companies were reducing worker hours to avoid ACA requirements for employees working more than 30 hours per week.


title: Affordable Care Act

text: CBO estimated that ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Jonathan Cohn claimed that ACA's primary employment effect was to alleviate job lock and the reform's only significant employment impact was the retirement of those who were working only to stay insured.


title: Affordable Care Act

text: Public views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Approval varied by party, race and age. Some elements were more widely favored (preexisting conditions) or opposed (individual mandate).


title: Affordable Care Act

text: In a 2010 poll, 62% of respondents said they thought ACA would "increase the amount of money they personally spend on health care", 56% said the bill "gives the government too much involvement in health care", and 19% said they thought they and their families would be better off with the legislation. Other polls found that people were concerned the law would cost more than projected and would not do enough to control costs.


title: Affordable Care Act

text: In a 2012 poll 44% supported the law, with 56% against. By 75% of Democrats, 27% of Independents and 14% of Republicans favored the law. 82% favored banning insurance companies from denying coverage to people with preexisting conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate. Other polls showed additional provisions receiving majority support, including the exchanges, pooling small businesses and the uninsured with other consumers and providing subsidies.


title: Affordable Care Act

text: Some opponents believed the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.


title: Affordable Care Act

text: In June 2013, a majority of the public (52–34%) indicated a desire for "Congress to implement or tinker with the law rather than repeal it". After the Supreme Court upheld the individual mandate, a 2012 poll held that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues".


title: Affordable Care Act

text: As of October 2013, approximately 40% were in favor while 51% were against. About 29% of whites approved of the law, compared with 61% of Hispanics and 91% of African Americans. A solid majority of seniors opposed the idea and a solid majority of those under forty were in favor.


title: Affordable Care Act

text: A 2014 poll reported that 26% of Americans support ACA. A later 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA versus 38.3% who had a favorable view (of more than 5,500 individuals). Another held that 8% of respondents agreed the Affordable Care Act "is working well the way it is". In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.


title: Affordable Care Act

text: In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved. A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.


title: Affordable Care Act

text: Separate polls from Fox News and NBC/"WSJ", both taken during January 2017, indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who had once opposed it (many still prefer "Medicare for all") shifted their positions because ACA was under threat of repeal. Another January 2017 poll reported that 35% of respondents believed "Obamacare" and the "Affordable Care Act" were different or did not know. (About 45% were unsure whether "repeal of Obamacare" also meant "repeal of the Affordable Care Act".) 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted," with Democrats far more likely (79%) to know that fact than Republicans (47%). A 2017 study found that personal experience with public health insurance programs led to greater support for the Affordable Care Act, most prominently among Republicans and low-information voters.


title: Affordable Care Act

text: The term "Obamacare" was originally coined by opponents as a pejorative. According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured. The term officially emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott wrote, "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care', 'Edwards-care', and a totally revamped and remodeled 'Hillary-care' from the 1990s". In May 2007 Mitt Romney introduced it to political discourse, saying, "How can we get those people insured without raising taxes and without having government take over healthcare?' And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."


title: Affordable Care Act

text: By mid-2012, Obamacare had become the colloquial term used both by supporters and opponents. Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."


title: Affordable Care Act

text: On August 7, 2009, Sarah Palin created the term "death panels" to describe groups who would decide whether sick patients were "worthy" of medical care. "Death panel" referred to two claims about early drafts.


title: Affordable Care Act

text: One was that under the law, seniors could be denied care due to their age and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an Independent Payment Advisory Board (IPAB). IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when statutory expenditure levels were exceeded within any given three-year period. In fact, the Board was prohibited from recommending changes that would reduce payments before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.


title: Affordable Care Act

text: The other related issue concerned advance-care planning consultation: a section of the House reform proposal would have reimbursed physicians for providing patient-requested consultations for Medicare recipients on end-of-life health planning (which is covered by many private plans), enabling patients to specify, on request, the kind of care they wished to receive. The provision was not included in ACA.


title: Affordable Care Act

text: In 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and 30% believed it was true, backed by three contemporaneous polls. The allegation was named PolitiFact's 2009 "Lie of the Year", one of FactCheck.org's "whoppers" and the most outrageous term by the American Dialect Society. AARP described such rumors as "rife with gross—and even cruel—distortions".


title: Affordable Care Act

text: ACA requires members of Congress and their staffs to obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the insurance offered to federal employees (the Federal Employees Health Benefits Program).


title: Affordable Care Act

text: Opponents claimed that combining immediate coverage with no provision for preexisting conditions would lead people to wait to get insured until they got sick. The individual mandate was designed to push people to get insured without waiting. This has been called a "death spiral". In the years after 2013, many insurers did leave specific marketplaces, claiming the risk pools were too small.


title: Affordable Care Act

text: The median number of insurers per state was 4.0 in 2014, 5.0 in 2015, 4.0 in 2016 and 3.0 in 2017. Five states had one insurer in 2017, 13 had two, 11 had three; the remainder had four or more.


title: Affordable Care Act

text: At various times during and after ACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan." However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated, and several million more risked seeing their current plans canceled.


title: Affordable Care Act

text: PolitiFact cited various estimates that only about 2% of the total insured population (4million out of 262 million) received such notices. Obama's previous unambiguous assurance that consumers could keep their own plans became a focal point for critics, who challenged his truthfulness. Various bills were introduced in Congress to allow people to keep their plans. PolitiFact later scored Obama's claims as the 2013 "Lie of the Year".


title: Affordable Care Act

text: Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions, conservative advocacy groups, Republicans, small business organizations and the Tea Party movement. These groups claimed the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit. Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods. President Donald Trump repeatedly promised to "repeal and replace" it.


title: Affordable Care Act

text: In October 2016, Mark Dayton, the governor of Minnesota and a member of the Minnesota Democratic–Farmer–Labor Party, said ACA had "many good features" but it was "no longer affordable for increasing numbers of people"; he called on the state legislature to provide emergency relief to policyholders. Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.


title: Affordable Care Act

text: Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds. The Supreme Court ruled, 5–4, that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.


title: Affordable Care Act

text: The Court further determined that states could not be forced to expand Medicaid. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.


title: Affordable Care Act

text: In March 2012, the Roman Catholic Church, while supportive of ACA's objectives, voiced concern through the United States Conference of Catholic Bishops that aspects of the mandate covering contraception and sterilization and HHS's narrow definition of a religious organization violated the First Amendment right to free exercise of religion and conscience. Various lawsuits addressed these concerns, including "Burwell v. Hobby Lobby Stores, Inc.", which looked at private corporations and their duties under the ACA.


title: Affordable Care Act

text: In "Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania", the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice Clarence Thomas said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the [administration], that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice Elena Kagan filed a concurring opinion in the judgment, in which Stephen Breyer joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."


title: Affordable Care Act

text: On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.


title: Affordable Care Act

text: House Republicans sued the Obama administration in 2014, alleging that cost-sharing reduction subsidy payments to insurers were unlawful because Congress had not appropriated funds to pay for them. The argument classified the CSR subsidy as discretionary spending subject to annual appropriation. In May 2016, a federal judge ruled for the plaintiffs, but the Obama administration appealed. Later, President Trump ended the payments. This led to further litigation.


title: Affordable Care Act

text: The House sued the administration, alleging that the money for CSRs to insurers had not been appropriated, as required for any federal government spending. The ACA subsidy that helps customers pay premiums was not part of the suit.


title: Affordable Care Act

text: Without the CSRs, the government estimated that premiums would increase by 20% to 30% for silver plans. In 2017, the uncertainty about whether the payments would continue caused Blue Cross Blue Shield of North Carolina to try to raise premiums by 22.9% the next year, as opposed to an increase of 8.8% that it would have sought if the payments were assured.


title: Affordable Care Act

text: U.S. District Judge Rosemary M. Collyer ruled that the cost-sharing program was unconstitutional for spending money that has not been specifically provided by an act of Congress, but concluded that Congress had in fact authorized that program to be created. The judge also found that Congress had provided authority to cover the spending for the tax credits to consumers who use them to help afford health coverage. Collyer enjoined further cost-sharing payments, but stayed the order pending appeal to the United States Court of Appeals for the District of Columbia Circuit. The case ended in a settlement before the Circuit Court.


title: Affordable Care Act

text: Texas and 19 other states filed a civil suit in the United States District Court for the Northern District of Texas in February 2018, arguing that with the passage of the Tax Cuts and Jobs Act of 2017, which eliminated the tax for not having health insurance, the individual mandate no longer had a constitutional basis and thus the entire ACA was no longer constitutional. The Department of Justice said it would no longer defend the ACA in court, but 17 states led by California stepped in to do so.


title: Affordable Care Act

text: District Judge Reed O'Connor of Texas ruled for the plaintiffs on December 14, 2018, writing that the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional." He then further reasoned that the individual mandate is an essential part of the entire law, and thus was not severable, making the entire law unconstitutional. O'Connor's decision regarding severability turned on several passages from the Congressional debate that focused on the importance of the mandate. While he ruled the law unconstitutional, he did not overturn the law.


title: Affordable Care Act

text: The intervening states appealed the decision to the Fifth Circuit. These states argued that Congress's change in the tax was only reducing the amount of the tax, and that Congress had the power to write a stronger law to this end. O'Connor stayed his decision pending the appeal. The Fifth Circuit heard the appeal on July 9, 2019; in the interim, the U.S. Department of Justice joined with Republican states to argue that the ACA was unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. An additional question was addressed, as the Republican plaintiffs challenged the Democratic states' standing to defend the ACA.


title: Affordable Care Act

text: In December 2019, the Fifth Circuit agreed the individual mandate was unconstitutional, but did not agree that the entire law should be voided. Instead, it remanded the case to the District Court for reconsideration of that question. The Supreme Court accepted the case in March 2020, to be heard in the 2020–2021 term, with the ruling likely falling after the 2020 elections.


title: Affordable Care Act

text: Democrats pointed out that the effect of invalidating the entire law would be to remove popular provisions such as the protection for preexisting conditions, and that the Republicans had still not offered any replacement plan—important issues in the 2020 elections.


title: Affordable Care Act

text: On June 17, 2021, the Court rejected the challenge in a 7–2 decision, ruling that Texas and the other plaintiff states did not have standing to challenge the provision, leaving the full ACA intact.


title: Affordable Care Act

text: The Supreme Court ruled that promised risk corridor payments must be made even in the absence of specific appropriation of money by Congress.


title: Affordable Care Act

text: Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements over which they had discretion. For example, Missouri declined to expand Medicaid or establish a health insurance marketplace engaging in active non-cooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law. Other Republicans discouraged efforts to advertise the law's benefits. Some conservative political groups launched ad campaigns to discourage enrollment.


title: Affordable Care Act

text: ACA was the subject of many unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives Steve King and Michele Bachmann introduced bills in the House to repeal the ACA the day after it was signed, as did Senator Jim DeMint in the Senate. In 2011, after Republicans gained control of the House, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189. All Republicans and three Democrats voted for repeal. In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down. President Obama said he would veto the bill had it passed.


title: Affordable Care Act

text: On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.


title: Affordable Care Act

text: Strong partisan disagreement in Congress prevented adjustments to the Act's provisions. But at least one change, a proposed repeal of a tax on medical devices, received bipartisan support. Some Congressional Republicans argued against improvements to the law on the grounds that they would weaken the arguments for repeal.


title: Affordable Care Act

text: Republicans attempted to defund the ACA's implementation, and in October 2013 House Republicans refused to fund the federal government unless it came with an implementation delay, after Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay the ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership said the Senate would pass only a bill without any restrictions on ACA. The government shutdown lasted from October 1 to October 17.


title: Affordable Care Act

text: During a midnight congressional session starting January 11, the Senate of the 115th Congress of the United States voted to approve a "budget blueprint" that would allow Republicans to repeal parts of the law "without threat of a Democratic filibuster". The plan, which passed 51–48, was named by Senate Republicans the "Obamacare 'repeal resolution. Democrats opposing the resolution staged a protest during the vote.


title: Affordable Care Act

text: House Republicans announced their replacement, the American Health Care Act, on March 6. On March 24, the AHCA failed amid a revolt among Republican representatives.


title: Affordable Care Act

text: On May 4 the House voted to pass the AHCA by a margin of 217 to 213. The Senate Republican leadership announced that Senate Republicans would write their own version of the bill instead of voting on the House version.


title: Affordable Care Act

text: Leader McConnell named a group of 13 Republicans to draft the substitute version in private, raising bipartisan concerns about lack of transparency. On June 22, Republicans released the first discussion draft, which renamed it the "Better Care Reconciliation Act of 2017" (BCRA). On July 25, although no amendment proposal had garnered majority support, Republicans voted to advance the bill to the floor and begin formal consideration of amendments. Senators Susan Collins and Lisa Murkowski were the only two dissenting Republicans, making the vote a 50–50 tie. Vice President Mike Pence then cast the tie-breaking vote in the affirmative.


title: Affordable Care Act

text: The revised BCRA failed, 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but that too failed, 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to ACA, failed by 49–51, with Collins, Murkowski, and McCain joining all Democrats and independents in voting against it.


title: Affordable Care Act

text: Under both the ACA (current law) and the AHCA, the CBO reported that the health exchange marketplaces would remain stable. But Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums. Concern about the exchanges became another argument for reforms. Past and ongoing Republican attempts to weaken the law have included:


title: Affordable Care Act

text: Many economically conservative opponents called the ACA "socialist" or "socialized medicine", pointing to the government redistribution of wealth via subsidies for low-income purchasers, expansion of the government-run Medicaid insurance, government requirements as to what products can be sold on the exchanges, and the individual mandate, which reduces freedom of consumer choice to be uninsured.


title: Affordable Care Act

text: Other observers considered the law a relatively capitalist or "regulated free-market" means of paying for near-universal health care, because it creates new marketplaces with choices for consumers, largely relies on private employers and private health insurance companies, maintains private ownership of hospitals and doctor's offices, and was originally advocated for by economic conservatives as a capitalist alternative to single-payer health care. Some pointed out that the previous system also had socialist aspects. Even for-profit private health insurance companies socialize risk and redistribute wealth from people who have it (all premium payers) to those who need it (by paying for medically necessary healthcare). The requirement to provide emergency care also forced redistribution from people who pay insurance premiums to those who choose to be uninsured, when they visit the emergency room.


title: Affordable Care Act

text: Some Obamacare supporters accused conservatives of using the term "socialism" as a scare tactic for Obamacare as it was for Medicare and Medicaid, and some embraced the label "socialism" as desirable, distinguishing democratic socialism as most desirable for education and health care, and communism as undesirable. Milos Forman opined that critics "falsely equate Western European-style socialism, and its government provision of social insurance and health care, with Marxist–Leninist totalitarianism".


title: Affordable Care Act

text: In 2010 small business tax credits took effect. Then Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those who had been denied coverage by private insurance companies because of a preexisting condition. By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement. In "National Federation of Independent Business v. Sebelius" the Supreme Court allowed states to opt out of the Medicaid expansion.


title: Affordable Care Act

text: In 2013, the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold. On July2 Obama delayed the employer mandate until 2015. The launch for both the state and federal exchanges was beset by management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered many problems. Operations stabilized in 2014, although not all planned features were complete.


title: Affordable Care Act

text: The Government Accountability Office released a non-partisan study in 2014 that concluded the administration had not provided "effective planning or oversight practices" in developing the exchanges. In "Burwell v. Hobby Lobby" the Supreme Court exempted closely held corporations with religious convictions from the contraception rule. At the beginning of the 2015, 11.7 million had signed up (ex-Medicaid). By the end of the year about 8.8 million consumers had stayed in the program. Congress repeatedly delayed the onset of the "Cadillac tax" on expensive insurance plans first until 2020 and later until 2022 and repealed it in late 2019.


title: Affordable Care Act

text: An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults. The five major national insurers expected to lose money on ACA policies in 2016, in part because the enrollees were lower income, older and sicker than expected.


title: Affordable Care Act

text: More than 9.2 million people (3.0 million new customers and 6.2 million returning) enrolled on the national exchange in 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump. The eleven states that run their own exchanges signed up about 3million more. The IRS announced that it would not require that tax returns indicate a person has health insurance, reducing the effectiveness of the individual mandate, in response to Trump's executive order. The CBO reported in March that the healthcare exchanges were expected to be stable. In May the House voted to repeal ACA using the American Health Care Act. The individual mandate was repealed starting in 2019 via the Tax Cuts and Jobs Act. The CBO estimated that the repeal would cause 13 million fewer people to have health insurance in 2027.


title: Affordable Care Act

text: The 2017 Individual Market Stabilization Bill was proposed to fund cost cost-sharing reductions, provide more flexibility for state waivers, allow a new "Copper Plan" offering only catastrophic coverage, allow interstate insurance compacts, and redirect consumer fees to states for outreach. The bill failed.


title: Affordable Care Act

text: By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicaid or via an alternative program.


title: Affordable Care Act

text: "SNL" presented a skit in October 2009 about the legislation's gridlock, with Dwayne Johnson playing an angry President Obama confronting three senators opposing the plan.


title: Affordable Care Act

text: The show aired another skit in September 2013 with Jay Pharoah as President Obama rolling out the plan to the public, and Aaron Paul and other cast members playing ordinary Americans helping him in advocating for the legislation.


title: Affordable Care Act

text: Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN; also available from Finance.Senate.Gov (accessed April 1, 2012).


title: Pearson (TV series)

text: Pearson is an American political drama television series created by Aaron Korsh and Daniel Arkin that premiered on USA Network. It is a spin-off of the show "Suits" and stars Gina Torres, who reprises her role of Jessica Pearson. It premiered on July 17, 2019. In October 2019, the series was canceled after one season.


title: Pearson (TV series)

text: "Pearson" follows "powerhouse lawyer Jessica Pearson, as she enters the dirty world of Chicago politics."


title: Pearson (TV series)

text: "For the backdoor pilot, "No. overall" and "No. in season" refer to the episode's place in the order of episodes of the parent series" Suits.


title: Pearson (TV series)

text: On February 22, 2017, it was announced that USA Network was developing a spin-off series of their show "Suits" set to star Gina Torres as her character Jessica Pearson. The spin-off had been talked about for about a year and a half prior to the announcement. Meetings and negotiations were reportedly in the preliminary stages with no deals with cast and crew members yet in place. The series was expected to be written by "Suits" creator and showrunner, Aaron Korsh, who was also expected to executive and showrun the potential new series. Production companies involved with the potential series were expected to include Universal Cable Productions. On March 1, 2017, it was reported that Gina Torres had signed a deal to produce the series, based on an idea she pitched to Universal Cable Productions, alongside Aaron Korsh.


title: Pearson (TV series)

text: On August 16, 2017, it was announced that the season seven finale of "Suits" would serve as a backdoor pilot to the spin-off series. The episode was expected to be written by Aaron Korsh and Daniel Arkin, and be directed by Anton Cropper. Additionally, it was reported that executive producers for the new series would include Korsh, Arkin, Torres, Doug Liman, David Bartis, and Gene Klein. On March 8, 2018, it was reported that USA Network had given the production a series order. On May 14, 2018, Gina Torres announced at NBCUniversal's annual upfront presentation in New York City that the series would be titled "Second City". On January 17, 2019, it was announced that the series had been retitled "Pearson". On May 1, 2019, it was reported that the series would premiere on July 17, 2019. On November 1, 2019, the USA Network canceled the series after one season.


title: Pearson (TV series)

text: Alongside the report of her hiring as producer, it was confirmed in March 2017 that Gina Torres would officially star in the potential series. On November 10, 2017, it was announced that Rebecca Rittenhouse and Morgan Spector had joined the main cast of the series. On September 20, 2018, it was reported that Rittenhouse's role had been recast with Bethany Joy Lenz assuming the part. Additionally, it was further announced that Chantel Riley would reprise her guest role from the backdoor pilot in a series regular capacity and that Isabel Arraiza and Eli Goree had been cast in main roles as well.


title: Pearson (TV series)

text: Principal photography for the series commenced on September 20, 2018, in Los Angeles, California. Filming took place in Chicago, Illinois during the week of October 15, 2018 with locations including the Chicago Cultural Center, Grant Park, Chicago City Hall, Millennium Park, and The Loop.


title: Pearson (TV series)

text: On the review aggregation website Rotten Tomatoes, the series has an approval rating of 72% with an average rating of 6.92/10, based on 18 reviews. The website's critical consensus reads, "Though "Pearson" trades the juicy intrigue of "Suits" for straightforward political drama, it works thanks to Gina Torres's commanding performance." Metacritic, which uses a weighted average, assigned a score of 54 out of 100, based on 7 critics, indicating "mixed or average reviews".


title: Graphical user interface

text: The GUI ( or ), graphical user interface, is a form of user interface that allows users to interact with electronic devices through graphical icons and audio indicator such as primary notation, instead of text-based UIs, typed command labels or text navigation. GUIs were introduced in reaction to the perceived steep learning curve of CLIs (command-line interfaces), which require commands to be typed on a computer keyboard.


title: Graphical user interface

text: The actions in a GUI are usually performed through direct manipulation of the graphical elements. Beyond computers, GUIs are used in many handheld mobile devices such as MP3 players, portable media players, gaming devices, smartphones and smaller household, office and industrial controls. The term "GUI" tends not to be applied to other lower-display resolution types of interfaces, such as video games (where HUD ("head-up display") is preferred), or not including flat screens like volumetric displays because the term is restricted to the scope of 2D display screens able to describe generic information, in the tradition of the computer science research at the Xerox Palo Alto Research Center.


title: Graphical user interface

text: Designing the visual composition and temporal behavior of a GUI is an important part of software application programming in the area of human–computer interaction. Its goal is to enhance the efficiency and ease of use for the underlying logical design of a stored program, a design discipline named "usability". Methods of user-centered design are used to ensure that the visual language introduced in the design is well-tailored to the tasks.


title: Graphical user interface

text: The visible graphical interface features of an application are sometimes referred to as "chrome" or "GUI" (pronounced "gooey"). Typically, users interact with information by manipulating visual widgets that allow for interactions appropriate to the kind of data they hold. The widgets of a well-designed interface are selected to support the actions necessary to achieve the goals of users. A model–view–controller allows flexible structures in which the interface is independent of and indirectly linked to application functions, so the GUI can be customized easily. This allows users to select or design a different "skin" at will, and eases the designer's work to change the interface as user needs evolve. Good GUI design relates to users more, and to system architecture less.


title: Graphical user interface

text: Large widgets, such as windows, usually provide a frame or container for the main presentation content such as a web page, email message, or drawing. Smaller ones usually act as a user-input tool.


title: Graphical user interface

text: A GUI may be designed for the requirements of a vertical market as application-specific GUIs. Examples include automated teller machines (ATM), point of sale (POS) touchscreens at restaurants, self-service checkouts used in a retail store, airline self-ticket and check-in, information kiosks in a public space, like a train station or a museum, and monitors or control screens in an embedded industrial application which employ a real-time operating system (RTOS).


title: Graphical user interface

text: Cell phones and handheld game systems also employ application specific touchscreen GUIs. Newer automobiles use GUIs in their navigation systems and multimedia centers, or navigation multimedia center combinations.


title: Graphical user interface

text: A GUI uses a combination of technologies and devices to provide a platform that users can interact with, for the tasks of gathering and producing information.


title: Graphical user interface

text: A series of elements conforming a visual language have evolved to represent information stored in computers. This makes it easier for people with few computer skills to work with and use computer software. The most common combination of such elements in GUIs is the "windows, icons, text fields, canvases, menus, pointer" (WIMP) paradigm, especially in personal computers.


title: Graphical user interface

text: The WIMP style of interaction uses a virtual input device to represent the position of a pointing device's interface, most often a mouse, and presents information organized in windows and represented with icons. Available commands are compiled together in menus, and actions are performed making gestures with the pointing device. A window manager facilitates the interactions between windows, applications, and the windowing system. The windowing system handles hardware devices such as pointing devices, graphics hardware, and positioning of the pointer.


title: Graphical user interface

text: In personal computers, all these elements are modeled through a desktop metaphor to produce a simulation called a desktop environment in which the display represents a desktop, on which documents and folders of documents can be placed. Window managers and other software combine to simulate the desktop environment with varying degrees of realism.


title: Graphical user interface

text: Entries may appear in a list to make space for text and details, or in a grid for compactness and larger icons with little space underneath for text. Variations inbetween exist, such as a list with multiple columns of items and a grid of items with rows of text extending sideways from the icon.


title: Graphical user interface

text: Multi-row and multi-column layouts commonly found on the web are "shelf" and "waterfall". The former is found on image search engines, where images appear with a fixed height but variable length, and is typically implemented with the CSS property and parameter codice_1. A waterfall layout found on Imgur and Tweetdeck with fixed width but variable height per item is usually implemented by specifying codice_2.


title: Graphical user interface

text: Smaller app mobile devices such as personal digital assistants (PDAs) and smartphones typically use the WIMP elements with different unifying metaphors, due to constraints in space and available input devices. Applications for which WIMP is not well suited may use newer interaction techniques, collectively termed "post-WIMP" UIs.


title: Graphical user interface

text: As of 2011, some touchscreen-based operating systems such as Apple's iOS (iPhone) and Android use the class of GUIs named post-WIMP. These support styles of interaction using more than one finger in contact with a display, which allows actions such as pinching and rotating, which are unsupported by one pointer and mouse.


title: Graphical user interface

text: Human interface devices, for the efficient interaction with a GUI include a computer keyboard, especially used together with keyboard shortcuts, pointing devices for the cursor (or rather pointer) control: mouse, pointing stick, touchpad, trackball, joystick, virtual keyboards, and head-up displays (translucent information devices at the eye level).


title: Graphical user interface

text: There are also actions performed by programs that affect the GUI. For example, there are components like inotify or D-Bus to facilitate communication between computer programs.


title: Graphical user interface

text: Ivan Sutherland developed Sketchpad in 1963, widely held as the first graphical computer-aided design program. It used a light pen to create and manipulate objects in engineering drawings in realtime with coordinated graphics. In the late 1960s, researchers at the Stanford Research Institute, led by Douglas Engelbart, developed the On-Line System (NLS), which used text-based hyperlinks manipulated with a then-new device: the mouse. (A 1968 demonstration of NLS became known as "The Mother of All Demos.") In the 1970s, Engelbart's ideas were further refined and extended to graphics by researchers at Xerox PARC and specifically Alan Kay, who went beyond text-based hyperlinks and used a GUI as the main interface for the Smalltalk programming language, which ran on the Xerox Alto computer, released in 1973. Most modern general-purpose GUIs are derived from this system.


title: Graphical user interface

text: The Xerox PARC GUI consisted of graphical elements such as windows, menus, radio buttons, and check boxes. The concept of icons was later introduced by David Canfield Smith, who had written a thesis on the subject under the guidance of Kay. The PARC GUI employs a pointing device along with a keyboard. These aspects can be emphasized by using the alternative term and acronym for "windows, icons, menus, pointing device" (WIMP). This effort culminated in the 1973 Xerox Alto, the first computer with a GUI, though the system never reached commercial production.


title: Graphical user interface

text: The first commercially available computer with a GUI was 1979 PERQ workstation, manufactured by Three Rivers Computer Corporation. Its design was heavily influenced by the work at Xerox PARC. In 1981, Xerox eventually commercialized the Alto in the form of a new and enhanced system – the Xerox 8010 Information System – more commonly known as the Xerox Star. These early systems spurred many other GUI efforts, including Lisp machines by Symbolics and other manufacturers, the Apple Lisa (which presented the concept of menu bar and window controls) in 1983, the Apple Macintosh 128K in 1984, and the Atari ST with Digital Research's GEM, and Commodore Amiga in 1985. Visi On was released in 1983 for the IBM PC compatible computers, but was never popular due to its high hardware demands. Nevertheless, it was a crucial influence on the contemporary development of Microsoft Windows.


title: Graphical user interface

text: Apple, Digital Research, IBM and Microsoft used many of Xerox's ideas to develop products, and IBM's Common User Access specifications formed the basis of the GUIs used in Microsoft Windows, IBM OS/2 Presentation Manager, and the Unix Motif toolkit and window manager. These ideas evolved to create the interface found in current versions of Microsoft Windows, and in various desktop environments for Unix-like operating systems, such as macOS and Linux. Thus most current GUIs have largely common idioms.


title: Graphical user interface

text: GUIs were a hot topic in the early 1980s. The Apple Lisa was released in 1983, and various windowing systems existed for DOS operating systems (including PC GEM and PC/GEOS). Individual applications for many platforms presented their own GUI variants. Despite the GUIs advantages, many reviewers questioned the value of the entire concept, citing hardware limits, and problems in finding compatible software.


title: Graphical user interface

text: In 1984, Apple released a television commercial which introduced the Apple Macintosh during the telecast of Super Bowl XVIII by CBS, with allusions to George Orwell's noted novel "Nineteen Eighty-Four". The goal of the commercial was to make people think about computers, identifying the user-friendly interface as a personal computer which departed from prior business-oriented systems, and becoming a signature representation of Apple products.


title: Graphical user interface

text: Windows 95, accompanied by an extensive marketing campaign, was a major success in the marketplace at launch and shortly became the most popular desktop operating system.


title: Graphical user interface

text: In 2007, with the iPhone and later in 2010 with the introduction of the iPad, Apple popularized the post-WIMP style of interaction for multi-touch screens, and those devices were considered to be milestones in the development of mobile devices.


title: Graphical user interface

text: The GUIs familiar to most people as of the mid-late 2010s are Microsoft Windows, macOS, and the X Window System interfaces for desktop and laptop computers, and Android, Apple's iOS, Symbian, BlackBerry OS, Windows Phone/Windows 10 Mobile, Tizen, WebOS, and Firefox OS for handheld (smartphone) devices.


title: Graphical user interface

text: Since the commands available in command line interfaces can be many, complex operations can be performed using a short sequence of words and symbols. Custom functions may be used to facilitate access to frequent actions.


title: Graphical user interface

text: Command-line interfaces are more lightweight, as they only recall information necessary for a task; for example, no preview thumbnails or graphical rendering of web pages. This allows greater efficiency and productivity once many commands are learned. But reaching this level takes some time because the command words may not be easily discoverable or mnemonic. Also, using the command line can become slow and error-prone when users must enter long commands comprising many parameters or several different filenames at once. However, "windows, icons, menus, pointer" (WIMP) interfaces present users with many widgets that represent and can trigger some of the system's available commands.


title: Graphical user interface

text: GUIs can be made quite hard when dialogs are buried deep in a system or moved about to different places during redesigns. Also, icons and dialog boxes are usually harder for users to script.


title: Graphical user interface

text: WIMPs extensively use modes, as the meaning of all keys and clicks on specific positions on the screen are redefined all the time. Command-line interfaces use modes only in limited forms, such as for current directory and environment variables.


title: Graphical user interface

text: Most modern operating systems provide both a GUI and some level of a CLI, although the GUIs usually receive more attention.


title: Graphical user interface

text: GUI wrappers find a way around the command-line interface versions (CLI) of (typically) Linux and Unix-like software applications and their text-based UIs or typed command labels. While command-line or text-based applications allow users to run a program non-interactively, GUI wrappers atop them avoid the steep learning curve of the command-line, which requires commands to be typed on the keyboard. By starting a GUI wrapper, users can intuitively interact with, start, stop, and change its working parameters, through graphical icons and visual indicators of a desktop environment, for example.


title: Graphical user interface

text: Applications may also provide both interfaces, and when they do the GUI is usually a WIMP wrapper around the command-line version. This is especially common with applications designed for Unix-like operating systems. The latter used to be implemented first because it allowed the developers to focus exclusively on their product's functionality without bothering about interface details such as designing icons and placing buttons. Designing programs this way also allows users to run the program in a shell script.


title: Graphical user interface

text: Many environments and games use the methods of 3D graphics to project 3D GUI objects onto the screen. The use of 3D graphics has become increasingly common in mainstream operating systems (ex. Windows Aero, and Aqua (MacOS)) to create attractive interfaces, termed eye candy (which includes, for example, the use of drop shadows underneath windows and the cursor), or for functional purposes only possible using three dimensions. For example, user switching is represented by rotating a cube with faces representing each user's workspace, and window management is represented via a Rolodex-style flipping mechanism in Windows Vista (see Windows Flip 3D). In both cases, the operating system transforms windows on-the-fly while continuing to update the content of those windows.


title: Graphical user interface

text: The GUI is usually WIMP-based, although occasionally other metaphors surface, such as those used in Microsoft Bob, 3dwm, File System Navigator, File System Visualizer, 3D Mailbox, and GopherVR. Zooming (ZUI) is a related technology that promises to deliver the representation benefits of 3D environments without their usability drawbacks of orientation problems and hidden objects. In 2006, Hillcrest Labs introduced the first ZUI for television. Other innovations include the menus on the PlayStation 2, the menus on the Xbox, Sun's Project Looking Glass, Metisse, which was similar to Project Looking Glass, BumpTop, where users can manipulate documents and windows with realistic movement and physics as if they were physical documents, Croquet OS, which is built for collaboration, and compositing window managers such as Enlightenment and Compiz. Augmented reality and virtual reality also make use of 3D GUI elements.


title: Graphical user interface

text: 3D GUIs have appeared in science fiction literature and films, even before certain technologies were feasible or in common use.


title: Shaun White

text: Shaun Roger White (born September 3, 1986) is an American former professional snowboarder and skateboarder. He is a five-time Olympian and a three-time Olympic gold medalist in half-pipe snowboarding. He holds the world record for the most X Games gold medals and most Olympic gold medals by a snowboarder. He has also won 10 ESPY Awards throughout his career in various categories.


title: Shaun White

text: White was born in San Diego, California, to parents Cathy and Roger. When he was young his mother was a waitress and his father, who grew up surfing, worked for the San Clemente, California, water department. He is the youngest of four children. His ancestry includes Irish and Italian. He was born with a Tetralogy of Fallot, a congenital heart defect for which he required two open-heart operations before the age of one. White spent his early years riding the San Bernardino Mountains of Southern California with his family. They would stay in a van in resort parking lots.


title: Shaun White

text: At an early age White's skills drew admirers. Professional skateboarder Tony Hawk befriended the nine-year-old White at the Encinitas, California, YMCA skate park and mentored him, helping White turn pro in skateboarding at the age of 16. White has said that "Tony was my hero and I was too terrified to talk to him so every time I saw him at the skate park I would try to impress him with my skateboarding in the hopes that one day he would say something to me." White has won many titles on his skateboard, including the overall title of Action Sports Tour Champion, and was the first person to compete in and win both the Summer and Winter X Games in two different sports.


title: Shaun White

text: Following in his older brother Jesse White's footsteps, White switched from skiing to snowboarding at age six, and by age seven, he received his first sponsorship. White has participated in five Winter Olympics in his career. At the 2006, 2010, and 2018 Winter Olympics, White won gold in the snowboard halfpipe event. White has also participated in the Winter X Games, where he has won a medal every year since 2002. Including all winter X Games competitions through 2013, his medal count stands at 18 (13 gold, 3 silver, 2 bronze), among which is the first quadruple win streak by a male athlete in one discipline, the snowboard slopestyle. White's streak was snapped in 2007 when he lost to Andreas Wiig and Teddy Flandreau, with White taking the bronze. He won the Air & Style Contest in 2003 and 2004.


title: Shaun White

text: At the 2006 Winter Olympics, White won gold in the half-pipe. After his first run in qualifications, White was almost out of competition, scoring only 37.7. On his second run, he recorded a score of 45.3. In the finals, White recorded a score of 46.8 (50 is the highest possible score) to win. Fellow American Danny Kass won the silver with a points total of 44.0.


title: Shaun White

text: Executing a near-flawless second run, White captured his third consecutive snowboard halfpipe title at the 2008 U.S. Open Snowboarding Championships to go along with his third US Open slopestyle competition. This followed White's win at the 25th (2007) Burton US Open, where he placed third in slopestlyle and first in the halfpipe. At the 2007 Open, White was also crowned the first "Burton Global Open Champion". His take for the event was $100,000 (Global Open Champ), $20,000 (1st Place Halfpipe), $90,000 (3rd Place Slopestyle), and a new Corvette.


title: Shaun White

text: On November 16, 2008, White released his first video game "Shaun White Snowboarding" in North America (November 14, 2008, in Europe). "Shaun White Snowboarding" was the 20th best-selling game of December 2008 in the United States.


title: Shaun White

text: Controversy followed White's win on the 2009 SuperPipe at Winter X Games XIII. Kevin Pearce had five hits in the pipe, and all were the same tricks White did in his final run. White, on the other hand, had six hits and he started off his run with a big backside rodeo 540 where Pearce started his run off with a big grab. Although Pearce went bigger, he had fewer hits, and his first hit wasn't as technically difficult as White's first hit. Judges came to the conclusion that White deserved the better score because he started off with a more technical trick and he had one more hit than Pearce. With the win, White became the second competitor, after Tanner Hall, to win a gold medal in the SuperPipe in consecutive years at the Winter X Games. He also won a gold medal in Slopestyle, finally winning gold after two consecutive years of bronze.


title: Shaun White

text: On February 14, 2009, White won the FIS World Cup Men's Halfpipe event at Vancouver's Cypress Mountain. Out of the gate in his first qualifying run, he qualified immediately with the day's best score of 45.5. With a thumb sprained on an over-rotated backside 1080 in the second qualifying run, White clinched the event with the first of his two runs in the finals. His first finals run was awarded the highest score ever in FIS halfpipe, a 47.3.


title: Shaun White

text: At the 2010 Winter Olympics in Vancouver, White again won gold in the halfpipe. In the finals, White recorded a score of 46.8 on his first run, which proved a high enough score to secure the gold medal without a second run. He performed his second run anyway, as a victory lap, ending his run with a well-anticipated Double McTwist 1260 which he named The Tomahawk. This second run resulted in a record score of 48.4 (50 is the highest possible score) enlarging his margin of victory. His nearest competitor won the silver with a points total of 45.0 – 3.4 behind White.


title: Shaun White

text: After a sub-par performance in the Slopestyle and failing to reach the finals, White "redeemed" himself in the SuperPipe. With an 89, he sat in second place going into his 2nd of three runs. He completed the run, landing his infamous Double McTwist 1260 and finishing with a score of 97.33 to take the lead and claim the historical 4th straight Gold in the Winter X Games, held in Aspen, Colorado. The score tied an X Games record, which was set by White one year before. His 3rd run was a simple victory run featuring mostly straight air.


title: Shaun White

text: At Winter X, White became the first person in the history of the Winter X Games to score a perfect 100 in the men's Snowboard SuperPipe.


title: Shaun White

text: White won his 6th consecutive SuperPipe victory, making him the second participant ever to achieve this, with SnoCross racer Tucker Hibbert achieving his 6th consecutive victory earlier in the same day.


title: Shaun White

text: In December 2013, he won the third place in the Pipe & Slope contest at the FIS Snowboard World Cup in Copper Mountain, Colorado.


title: Shaun White

text: While in New Zealand, training for the 2018 Winter Olympics, White crashed into the edge of a superpipe; the resulting injuries to his face required 62 stitches. Despite the accident, White qualified for the 2018 US Olympic Team. On February 14, he won his third Olympic gold medal for the Men's Halfpipe event with a score of 97.75, with Ayumu Hirano of Japan taking the silver medal and Scott James of Australia taking the bronze. White was trailing Hirano by one full point coming into his last run with a score of 94.25. Despite this, White dramatically won the gold medal with back-to-back 1440s. His gold medal was also the 100th for the United States at the Winter Olympic Games.


title: Shaun White

text: During the winter games, White announced it would be the last Olympics in which he would compete. Later, he announced it would be his final competition altogether.


title: Shaun White

text: White has had a sponsor since he was seven years old. White signed CAA Sports for representation after working with IMG for eight years. Corporate endorsement deals include or have included Burton Snowboards, Oakley, Inc., Birdhouse Skateboards, Park City Mountain Resort, Target Corporation, Red Bull, Ubisoft, Adio, Hewlett-Packard, and American Express. He is also a brand ambassador for Krave Jerky and as part of their partnership he has developed and released his own flavors. In 2009, "Forbes" magazine estimated that he had earned $9 million from his endorsements in 2008.


title: Shaun White

text: White has made cameo appearances as himself in the 2011 film "Friends with Benefits", the 2013 episode "Da Flippity Flop" of the animated TV series "American Dad!", and the 2014 Disney Channel Original Movie "Cloud 9".


title: Shaun White

text: White starred in the 2004 documentary "The White Album" and the 2005 snowboarding documentary "First Descent".


title: Shaun White

text: In 2007, White appeared on the E! reality TV show "The Girls Next Door" as a snowboarding teacher for Holly Madison, Bridget Marquardt and Kendra Wilkinson.


title: Shaun White

text: A film, "Don't Look Down", was released on DVD and ESPN in 2009. The film tracks his journey through the year following his Olympic success.


title: Shaun White

text: White appeared on the January 16, 2011, episode of "" to help redesign a room for an eight-year-old boy.