{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T20:37:49Z","timestamp":1789936669607,"version":"4.0.1"},"reference-count":64,"publisher":"Cambridge University Press (CUP)","issue":"3","license":[{"start":{"date-parts":[[2021,1,1]],"date-time":"2021-01-01T00:00:00Z","timestamp":1609459200000},"content-version":"unspecified","delay-in-days":3288,"URL":"https:\/\/www.cambridge.org\/core\/terms"},{"start":{"date-parts":[[2012,1,1]],"date-time":"2012-01-01T00:00:00Z","timestamp":1325376000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J. Law. Med. Ethics"],"published-print":{"date-parts":[[2012]]},"abstract":"<jats:p>The Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act) is the law of the land. But it faces an uncertain future.<\/jats:p><jats:p>During congressional deliberations on the 2,700-page legislation leading up to its enactment, from February to March 2010, not one major survey recorded majority support for the legislation. Since its enactment, popular opposition to the Affordable Care Act has hardened, and was a significant factor in the 2010 congressional election, in which Democrats lost 63 seats and Republicans regained the majority in the House of Representatives. Ballot initiatives in Missouri and Ohio, showcasing popular opposition to the individual mandate, passed in 2010 with overwhelming majorities. While the United States Supreme Court in<jats:italic>National Federation of Independent Business et al. v. Sebelius, 132<\/jats:italic>S. Ct. 2566 ( 2012), declared the mandate on the states to expand Medicaid unconstitutionally coercive, the majority of the Justices also upheld the individual mandate as a permissible tax. The new law thus emerged as a central topic in the 2012 election.<\/jats:p>","DOI":"10.1111\/j.1748-720x.2012.00689.x","type":"journal-article","created":{"date-parts":[[2015,10,13]],"date-time":"2015-10-13T14:27:15Z","timestamp":1444746435000},"page":"558-573","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":4,"title":["Expanding Choice through Defined Contributions: Overcoming a Non-Participatory Health Care Economy"],"prefix":"10.1017","volume":"40","author":[{"given":"Robert E.","family":"Moffit","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"56","published-online":{"date-parts":[[2021,1,1]]},"reference":[{"key":"S1073110500016600_bib28","first-page":"32","volume-title":"Putting Medicare Consumers in Charge: Lessons from the FEHBP","author":"Francis","year":"2009"},{"key":"S1073110500016600_bib53","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2011.1026"},{"key":"S1073110500016600_bib15","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp1010850"},{"key":"S1073110500016600_bib64","unstructured":"62. See Butler, , supra note 58, at 27."},{"key":"S1073110500016600_bib17","unstructured":"17. President Barack Obama, \u201cRemarks by the President to a Joint Session of Congress on Health Care,\u201d The White House, September 9, 2009, available at <http:\/\/www.whitehouse.gov\/the_press_office\/remarks-by-the-president-to-a-joint-session-of-congress-on-health-care\/>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib8","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp1107184"},{"key":"S1073110500016600_bib45","unstructured":"43. See Francis, , supra note 28, at 27."},{"key":"S1073110500016600_bib49","unstructured":"47. Such criteria include appropriate testing, the use of certain drug therapies, mammograms, beta blockers for cardiovascular patients, and specific tests for diabetes."},{"key":"S1073110500016600_bib54","volume-title":"\u201cManaged Care, Choice and Patient Satisfaction,\u201d","author":"Davis","year":"1997"},{"key":"S1073110500016600_bib48","unstructured":"46. The data are from the Office of the Actuary, CMS, \u201cComparison of the Office of the Actuary's Original Title I MMA Cost Estimates to those Underlying the CY 2011 Trustees Report,\u201d August 2011."},{"key":"S1073110500016600_bib57","unstructured":"55. The United States Office of Personnel Management, Fiscal Year 2010: Summary of Performance and Financial Information, at 15, available at <http:\/\/www.opm.gov\/gpra\/opmgpra\/OPM2010_SummaryPFI.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib38","unstructured":"38. See Francis, , supra note 28, at 133."},{"key":"S1073110500016600_bib24","volume-title":"\u201cWhat Changes Will Health Reform Bring to Medicare Advantage Plan Benefits and Enrollment?\u201d","author":"Book","year":"2011"},{"key":"S1073110500016600_bib43","volume-title":"\u201cValue of Medicare Advantage to Low Income and Minority Medicare Beneficiaries,\u201d","author":"Atherly","year":"2005"},{"key":"S1073110500016600_bib26","volume-title":"\u201cThe Federal Employees Health Benefits program: Program Design, Recent Performance, and Implications for Medicare Reform,\u201d","author":"Merlis","year":"2003"},{"key":"S1073110500016600_bib47","unstructured":"45. Id."},{"key":"S1073110500016600_bib42","unstructured":"40. Kennedy, K. , \u201cMedicare Advantage: Enrollment is Up, Premiums are Down,\u201d USA Today, February 1, 2012, available at <http:\/\/www.usatoday.com\/news\/washington\/story\/2012-01-31\/medicare-advantage-enrollment-premiums\/52906712\/1>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib32","unstructured":"32. D'Angelo, G. , \u201cThe VA Drug Pricing Model: What Senators Should Know,\u201d Heritage Foundation WebMemo No. 1420, April 11, 2007, available at <http:\/\/www.heritage.org\/research\/reports\/2007\/04\/the-va-drug-pricing-model-what-senators-should-know>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib13","unstructured":"13. Elmendorf, D. W. , Letter to the Honorable Nancy Pelosi, Speaker, the U.S. House of Representatives, March 20, 2010, available at <http:\/\/www.cbo.gov\/ftpdocs\/113xx\/doc11379\/amendreconProp.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib18","volume-title":"Health Care Price Transparency: Meaningful Price Information Is Difficult for Consumers to Obtain Prior to Receiving Care","author":"Kohn","year":"2011"},{"key":"S1073110500016600_bib3","unstructured":"3. Rasmussen Reports, \u201c63% Favor Repeal of National Health Care Plan,\u201d May 24, 2010, available at <http:\/\/www.rasmussenreports.com\/public_content\/politics\/current_events\/healthcare\/may_2010\/63_favor_repeal_of_national_health_care_plan>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib22","volume-title":"\u201cEmployer Sponsored Health Insurance: Down But Not Out,\u201d","author":"Christianson","year":"2011"},{"key":"S1073110500016600_bib39","unstructured":"39. CMS Actuary Richard, S. Foster has said that the long-term viability of the Medicare payment reductions is \u201cdoubtful.\u201d See Foster, , supra note 10, at 21. Likewise, CBO Director Douglas Elmendorf has said that the new law had put policies into effect that would be \u201cdifficult to sustain.\u201d See Elmendorf, , supra note 13, at 14."},{"key":"S1073110500016600_bib20","unstructured":"20. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, 2011 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, May 13, 2011, at 41, available at <https:\/\/www.cms.gov\/reportstrust-funds\/downloads\/tr2011.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib10","volume-title":"\u201cEstimated Financial Effects of \u2018The Patient Protection and Affordable Care Act\u2019, as Amended,\u201d","author":"Foster","year":"2010"},{"key":"S1073110500016600_bib55","unstructured":"53. Id."},{"key":"S1073110500016600_bib9","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2011.0662"},{"key":"S1073110500016600_bib1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp1011714"},{"key":"S1073110500016600_bib12","unstructured":"12. Conover, C. J. , \u201cHealth Is the Health of the State,\u201d The American: The Journal of the American Enterprise Institute, July 19, 2011, available at <http:\/\/www.american.com\/archive\/2011\/july\/health-is-the-health-of-the-state>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib56","unstructured":"54. Id."},{"key":"S1073110500016600_bib46","unstructured":"44. Kliff, S. , \u201cWhat a 76-Cent Premium Decrease Says about Medicare's Future,\u201d Ezra Klein's Wonkblog, Washington Post, August 9, 2011, available at <http:\/\/www.washingtonpost.com\/blogs\/ezra-klein\/post\/what-a-76-cent-drug-premium-decrease-says-about-medicares-future\/2011\/08\/02\/gIQAZyI84I_blog.html>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib11","unstructured":"11. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, \u201cNational Health Expenditure Data: Historical,\u201d available at <http:\/\/www.cms.gov\/NationalHealthExpendData\/02_NationalHealthAccountsHistorical.asp#TopOfPage>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib36","unstructured":"36. See Francis, , supra note 28, at 112."},{"key":"S1073110500016600_bib50","first-page":"841","article-title":"\u201cComparing Quality of Care in the Medicare Program,\u201d","volume":"16","author":"Brennan","year":"2010","journal-title":"American Journal of Managed Care"},{"key":"S1073110500016600_bib59","unstructured":"57. KRC Research, \u201cSeniors Opinions about Medicare Rx: Sixth Year Update,\u201d October 2011, available at <http:\/\/www.hlc.org\/blog\/wp-content\/uploads\/2011\/10\/Oct-2011-KRC-Medicare-Today-Survey-of-Seniors-with-Medicare-Rx-10-14-11-FINAL1.pdf>(last visited August 23, 2012). In 2011, KRC survey found only 11 percent of respondents saying that they were not satisfied. The high rates of enrollee satisfaction in Medicare Part D have been consistent since March of 2006. Since the fall of 2007, more than half of enrollees have described themselves as being \u201cvery satisfied\u201d with the program."},{"key":"S1073110500016600_bib62","unstructured":"60. Sheils, J. , \u201cIdeas for Financing Health Reform: Revenue Measures That Also Reduce Health Spending: Statement for the Committee on Finance,\u201d May 12, 2009, available at <http:\/\/finance.senate.gov\/imo\/media\/doc\/John%20Sheils.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib34","unstructured":"34. Lemieux, J. , Memorandum to the Medicare Commission, The National Bipartisan Commission on the Future of Medicare, February 17, 1999, available at <http:\/\/medicare.commission.gov\/medicare\/jeff.html>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib5","unstructured":"5. Zogby Interactive Poll, \u201cZogby Interactive: 51% of Voters Oppose Healthcare Reform Act,\u201d April 21, 2010, available at <http:\/\/www.zogby.com\/news\/2010\/04\/21\/zogby-interactive-51-of-voters-oppose-healthcare-reform-act\/>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib33","volume-title":"\u201cHealth Insurance Costs to Rise Again Next Year,\u201d","author":"Brunswick","year":"2011"},{"key":"S1073110500016600_bib66","unstructured":"64. When the majority of the National Bipartisan Commission on the Future of Medicare endorsed a premium-support system of financing for the program in 1999, they proposed that the government pay 88 percent of the cost of a competing health plan, though they adjusted that contribution for income. Historically, taxpayers have financed, on a pay-go basis, roughly 88 percent of the Medicare program's total cost."},{"key":"S1073110500016600_bib52","doi-asserted-by":"publisher","DOI":"10.1016\/j.ahj.2010.04.023"},{"key":"S1073110500016600_bib19","unstructured":"19. See Elmendorf, , supra note 13, at Table 5."},{"key":"S1073110500016600_bib16","doi-asserted-by":"crossref","unstructured":"16. Matthews, M. , \u201cAmerica's Coming Health Care Oligopoly,\u201d Forbes, July 7, 2010, available at <http:\/\/www.forbes.com\/2010\/07\/07\/healthcare-reform-insurance-hospitals-contributors-merrill-matthews-obamacare.html>(last visited August 23, 2012).","DOI":"10.1063\/pt.4.0834"},{"key":"S1073110500016600_bib35","unstructured":"35. Congressional Research Service (CRS), The Federal Employees Health Benefits Program: Possible Strategies for Reform, May 24, 1989, at 255. This CRS study remains the most comprehensive analysis of the FEHBP."},{"key":"S1073110500016600_bib29","unstructured":"29. America's Health Insurance Plans, \u201cMedicare Advantage Plans,\u201d available at <http:\/\/www.ahip.org\/content\/default.aspx?bc=39%7C341%7C321>(last visited November 10, 2011)."},{"key":"S1073110500016600_bib7","unstructured":"7. Popular anxiety over costs, fear of losing coverage, and anger over insurance denials of claims or coverage have fueled majority support for major health care reform since the debate on the Clinton Health Security Act of 1993. For example, the Robert Wood Johnson\u2013Harvard School of Public Health Survey in March 1993 found that 56 percent of Americans wanted a major overhaul of the health care system. On March 1, 2007, the CBS News\/New York Times poll found that 54 percent of Americans wanted \u201cfundamental changes\u201d in the system. CBS News\/New York Times Poll, \u201cU.S. Health Care Politics,\u201d March 1, 2007, available at <http:\/\/www.cbsnews.com\/htdocs\/CBSNews_polls\/health_care.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib65","unstructured":"63. In a proposal developed by the Heritage Foundation, the funding for traditional Medicaid for the very poor and disabled would be converted into a capped amount and allotted to the states in the form of a block grant; the amount of that assistance would be annually indexed to the growth of medical inflation. While the states would be required to meet some basic national performance standards in the administration of the program, they would also have real flexibility in meeting these performance standards and in achieving national goals and outcomes. Id., at 25\u201328."},{"key":"S1073110500016600_bib37","unstructured":"37. O'Grady, M. J. , \u201cHealth Insurance Spending Growth: How Does Medicare Compare?\u201d Report prepared for the Joint Economic Committee, June 10, 2003, available at <http:\/\/ogradyhp.com\/yahoo_site_admin\/assets\/docs\/JEC_HI_Growth_Rate_reportfinal.238132146.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib51","unstructured":"49. America's Health Insurance Plans, Center for Policy and Research, \u201cWorking Paper: A Preliminary Comparison of Utilization Measures Among Diabetes and Heart Disease Patients in Eight Regional Medicare Advantage Plans and Medicare Fee-for Service in the Same Service Areas,\u201d September 2009, available at <www.ahip.org\/MA-vs-FFS-Report-2009\/>(last visited August 27, 2012). The findings were based on risk-adjusted data."},{"key":"S1073110500016600_bib31","unstructured":"31. Id."},{"key":"S1073110500016600_bib4","unstructured":"4. Rasmussen Reports, \u201c52% Favor Repeal of Health Care Bill,\u201d June 28, 2010, available at <http:\/\/www.rasmussenreports.com\/public_content\/politics\/current_events\/healthcare\/june_2010\/52_favor_repeal_of_health_care_bill>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib30","unstructured":"30. The Lewin Group, \u201cComparison of VA National Formulary and Formularies of the Highest Enrollment Plans in Medicare Part D and the Federal Employee Health Benefit Program,\u201d December 10, 2008, available at <http:\/\/www.lewin.com\/\u223c\/media\/lewin\/site_sections\/publications\/3987.pdf>(last visited August 27, 2012)."},{"key":"S1073110500016600_bib2","unstructured":"2. Congressional Republicans campaigned against the legislation, while most Democrats ran away from defending the new law. Exit polling showed deep dissatisfaction with the new law, with voters nearly split on whether it should be repealed. Fox News, \u201cNewly Empowered House Republicans Eye Repeal of \u2018Obamacare,\u2019\u201d November 3, 2010, available at <http:\/\/www.foxnews.com\/politics\/2010\/11\/03\/newly-empowered-house-republicans-eye-repeal-obamacare>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib44","unstructured":"42. The Medicare Payment Advisory Commission, Report to Congress: Medicare and the Health Care Delivery System, June 2011, at 68, available at <http:\/\/www.medpac.gov\/documents\/Jun11_EntireReport.pdf>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib27","unstructured":"27. Francis, W. , \u201cThe FEHBP as a Model for Medicare Reform: Separating Fact from Fiction,\u201d Heritage Foundation Backgrounder No. 1674, August 7, 2003, available at <http:\/\/www.heritage.org\/research\/reports\/2003\/08\/the-fehbp-as-a-model-for-medicare-reform-separating-fact-from-fiction>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib14","unstructured":"14. Krugman, P. , \u201cMedicine: Who Decides?\u201d New York Times, December 26, 2005, at A-31."},{"key":"S1073110500016600_bib63","unstructured":"61. Carroll, R. Opinion, , \u201cAlmost Everyone Would Do Better Under the McCain Health Plan,\u201d Wall Street Journal, October 27, 2008, available at <http:\/\/online.wsj.com\/article\/SB122506862956370705.html>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib61","unstructured":"59. Cunningham, R. , \u201cJoint Custody: Bipartisan Interest Expands Scope of Tax-Credit Proposals,\u201d Health Affairs (September 18, 2002), available at <http:\/\/content.*healthaffairs.org\/content\/early\/2002\/09\/18\/hlthaff.w2.290.citation>(last visited August 28, 2012)."},{"key":"S1073110500016600_bib60","volume-title":"Saving The American Dream: The Heritage Plan to Fix the Debt, Cut Spending and Restore Prosperity","author":"Butler","year":"2011"},{"key":"S1073110500016600_bib25","unstructured":"25. Specifically, Congress provided a $250 rebate for Medicare beneficiaries who entered the \u201cdonut hole,\u201d a pre-ordained gap in drug coverage where beneficiaries pay 100 percent of drug costs until they reach a specified catastrophic threshold. A feature of the Medicare Modernization Act of 2003, the donut hole was purely the product of congressional imagination. It was a way to provide a universal drug entitlement while attempting to control costs by creating an interim out-of pocket payment requirement. No such benefit design was found in the private sector. The Affordable Care Act basically fills up the \u201chole.\u201d It requires companies to provide a 50 percent discount for brand-name drugs, and it imposes a 25 percent cap on total benefciary costs for those who find themselves in the \u201cdonut hole.\u201d."},{"key":"S1073110500016600_bib58","unstructured":"56. Ayres, McHenry, and Associates, \u201cNational Survey of Seniors Regarding Medicare Advantage,\u201d February 26-March 2, 2007."},{"key":"S1073110500016600_bib6","unstructured":"6. Hacker, J. , \u201cHealth Reform 2.0,\u201d The American Prospect, July 2010, available at <http:\/\/prospect.org\/article\/health-reform-20-0>(last visited August 23, 2012)."},{"key":"S1073110500016600_bib23","volume-title":"\u201cLegal Analysis of Section 1311(e)(1)(B) of the Patient Protection and Affordable Care Act and State Sponsored Public Health Plans,\u201d","author":"Staman","year":"2010"},{"key":"S1073110500016600_bib21","unstructured":"21. United States Department of Justice & Federal Trade Commission, \u201cCompetition Law: Hospitals,\u201d Improving Health Care: A Dose of Competition, July 2004, at 1, available at <http:\/\/www.ftc.gov\/reports\/healthcare\/040723healthcarerpt.pdf>(last visited August 23, 2012)."}],"container-title":["Journal of Law, Medicine &amp; Ethics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Fj.1748-720X.2012.00689.x","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/journals.sagepub.com\/doi\/pdf\/10.1111\/j.1748-720X.2012.00689.x","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/S1073110500016600","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,5,31]],"date-time":"2025-05-31T00:45:58Z","timestamp":1748652358000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cambridge.org\/core\/product\/identifier\/S1073110500016600\/type\/journal_article"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2012]]},"references-count":64,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2012]]}},"alternative-id":["S1073110500016600"],"URL":"https:\/\/doi.org\/10.1111\/j.1748-720x.2012.00689.x","relation":{},"ISSN":["1073-1105","1748-720X"],"issn-type":[{"value":"1073-1105","type":"print"},{"value":"1748-720X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2012]]}}}