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State Spending On Consumer Assistance Could Have ‘Huge Impact’ On Marketplace Enrollment
State Spending On Consumer Assistance Could Have ‘Huge Impact’ On Marketplace Enrollment
Source: Kaiser Health News
Florida is on course to spend $6 million to reach out to nearly 4 million uninsured people and help them sign up for coverage in the federal health law’s online marketplace this fall.
Maryland will spend more than four times as much, or about $24.8 million, to help about 730,000 uninsured. The District of Columbia expects to spend about $9 million assisting 42,000 uninsured.
The wide variation in spending to hire and train people to provide consumer assistance in the first year of the new marketplaces could have a major impact on how many people actually get coverage under Obamacare, experts say.
Yet states with some of the nation’s highest uninsured rates, such as Florida and Texas, are getting far less federal money per uninsured resident than states with low rates, such as Maryland, Vermont and Rhode Island, according to a Kaiser Health News analysis.
Bending the Curve: Person-Centered Health Care Reform
Bending the Curve: Person-Centered Health Care Reform
Source: Brookings Institution
We propose a framework for health care reform that focuses on supporting person-centered care. With continued innovation toward more personalized care, this is the best way to improve care and health while also bending the curve of health care cost growth.
Our health care system holds great promise. As a result of fundamental breakthroughs in biomedical science, improvements in data systems and network capabilities, and continuing innovation in health care delivery, care is becoming increasingly individualized and prevention-oriented. The best treatment for a patient involves not just specific services covered under traditional approaches to health insurance financing, but also includes new technologies and new kinds of care and support at home and beyond traditional health care settings. These advances require health care providers to work with patients and their caregivers to target increasingly sophisticated treatments and to coordinate care effectively ways that works best for each patient.
Our report’s person-focused reforms aim to support these changes in care—not as an afterthought or as an addition to our health care financing and regulation, but as the core goal. Instead of having to work around fee-for-service (FFS) payments and regulations that can complicate getting the highest-value care in each case, providers and patients will be able to receive more support for the specific approaches to care delivery that can make the most difference. The support comes from aligning reforms in provider payment, benefit design, regulation, and health plan payment and competition. To avoid short-term disruptions, our systematic framework involves a clear path that builds on existing reforms in the public and private sector, supports transitional steps to assist providers, and includes close evaluation and opportunities for adjustments along the way. While our primary goal is better health through better care, we estimate that our reforms would achieve an estimated $300 billion or more in net federal savings in the next decade, and provide a path to sustaining per capita cost growth that is much more in line with per capita growth in Gross Domestic Product (GDP). After the proposed reforms are implemented in the coming decade, long-term savings from achieving better health and sustainable spending growth will exceed $1 trillion over 20 years. Our proposals can be scaled up or down, and can also be combined with other proposed reforms to achieve additional reductions in health care costs. Our approach enables Congress to focus on overall cost, quality, and access goals that are very difficult to address under current law – so that whatever the spending level, that spending will do more for health.
These issues of health care quality and cost must be addressed. If a clear framework like ours is not implemented, the alternative is likely to be continued reliance on short-term cost controls, including across-the-board cuts in payments like sequestration, or delays and restrictions in both needed coverage updates for vulnerable populations and new types of innovative care—perpetuating large gaps in quality of care.
Our proposals represent an alternative to such care disruptions, cost-shifting, and threats to more innovative, person-focused care. We include proposals for Medicare, Medicaid, and private health insurance. We also propose a set of system-wide regulatory reforms and other initiatives, including antitrust and liability reforms. While some of these proposals are specific to particular programs and regulations, they are all grounded in our core goal of supporting quality care resulting in lower cost. This means a clear path for moving away from FFS payments and benefits and open-ended subsidies for insurance plan choices toward a direct focus on supporting better care and lower costs at the person level. Our proposals encompass significant reforms – such as modifications in Medicare payment mechanisms and benefits, and a change in the tax exclusion for employer-provided health insurance. The proposals reflect ideas that have gathered broad support in the past, but also include new approaches for addressing some of their shortcomings. Implementing our reforms together enables them to reinforce each other and create much more momentum for improving care while bending the cost curve.
Immigration Reform: A Long Road to Citizenship and Insurance Coverage
Immigration Reform: A Long Road to Citizenship and Insurance Coverage
Source: Health Affairs
The 2012 presidential election transformed the national debate regarding unauthorized immigrants and US immigration policy in general. There had long been strong political resistance, especially among Republicans, to legalizing unauthorized immigrants. But on Election Day 2012, Latino voters turned out in large numbers, affecting the results in Florida and several Southwestern states and helping propel President Barack Obama to reelection. Republican losses in key states were attributed in part to voters’ perceptions that the party’s rhetoric on immigration had been too harsh. Almost overnight, immigration reform seemed to rise from the bottom to the top of Washington’s policy agenda.
No one has more at stake in this development than the estimated 11 million unauthorized immigrants in the United States.1 As of 2007 almost 60 percent of unauthorized immigrants lacked health insurance, and they accounted for about one-seventh of the country’s uninsured population.2,3
Yet as the Affordable Care Act is fully implemented, and millions of people gain access to coverage through new private insurance options or an expanded Medicaid program, under the law unauthorized immigrants will still be frozen out. Legally present immigrants without permanent resident status, such as students and temporary workers, will also be excluded from Medicaid, as will adults and, in some states, children who have been permanent residents for fewer than five years.
Uninsured Veterans and Family Members: State and National Estimates of Expanded Medicaid Eligibility Under the ACA
Uninsured Veterans and Family Members: State and National Estimates of Expanded Medicaid Eligibility Under the ACA
Source: Urban Institute
Analysis of the 2008-2010 American Community Survey indicates that 535,000 uninsured veterans and 174,000 uninsured spouses of veterans —or 4 in 10 uninsured veterans and 1 in 4 uninsured spouses—have incomes below 138 percent of poverty and could qualify for Medicaid or new subsidies for coverage under the Affordable Care Act. Most have incomes below 100 percent of poverty and will only have new coverage options if their state expands Medicaid. Since uninsurance is related to greater problems accessing care, increased Medicaid enrollment could improve the likelihood that their health care needs are being met.
How Has CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage Provisions Changed Over Time?
How Has CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage Provisions Changed Over Time?
Source: Congressional Budget Office
When the ACA and other proposals that led up to that legislation were being considered by the Congress in 2009 and 2010, CBO and JCT prepared estimates of those proposals’ budgetary effects over the 2010–2019 period. In the estimate prepared in March 2010, CBO and JCT projected that the provisions of the ACA related to health insurance coverage would cost the federal government $788 billion between 2010 and 2019. The latest projections extend the original ones by four years, corresponding to the shift in the regular 10-year projection period since 2009, and the estimated cost of the ACA’s insurance coverage provisions between 2013 and 2023 is $1,329 billion. However, the projections for each given year have changed little, on net, since March 2010—as shown in the figure.
Ensuring the Health Care Needs of Women: A Checklist for Health Exchanges
Ensuring the Health Care Needs of Women: A Checklist for Health Exchanges
Source: Kaiser Family Foundation
To inform the development of the state health insurance Exchanges under the Affordable Care Act, this checklist identifies key coverage, affordability and access issues that are important for women. Based on lessons learned from women’s health research and the Massachusetts experience, the checklist considers essential health benefits, implementation of no-cost preventive services including contraception, provider networks and affordability, outreach and enrollment efforts, and the importance of including gender and other demographic characteristics in data collection and reporting standards. It was jointly authored by policy experts at the Kaiser Family Foundation, The Connors Center for Women’s Health and Gender Biology at the Brigham and Women’s Hospital and the Jacobs Institute of Women’s Health at The George Washington University.
Quick Health Facts 2012: Selected State Data on Older Americans
Quick Health Facts 2012: Selected State Data on Older Americans
Source: AARP Public Policy Institute
Quick Health Facts 2012: Selected State Data on Older Americans provides a snapshot of each state’s health care landscape by providing comparable state-level and national data for over 70 indicators. This report, which is part of a biannual series on state-level data, is designed to reflect current health care priorities, with a particular focus on data that is relevant to the provisions of the recently upheld health care reform legislation. For example:
- The Demographics section presents data on the 50- to 64-year-old population that shows what percentage of the population could be eligible for health insurance premium and cost-sharing assistance starting in 2014.
- In the Medicare section, the number of Medicare Part B beneficiaries who paid an income-related premium in 2008 is an indicator of how many Medicare Part D enrollees could pay an income-related premium.
- The Coverage and Capacity section includes data on private employers that currently offer health care coverage; many employers will be required to offer health insurance starting in 2014.
In some cases, indicators have been broken down into age subsets to highlight the variation among different age groups.
CRS — Medicare, Medicaid, and Other Health Provisions in the American Taxpayer Relief Act of 2012
Medicare, Medicaid, and Other Health Provisions in the American Taxpayer Relief Act of 2012 (PDF)
Source: Congressional Research Service (via Federation of American Scientists)
Several policies that would have reduced spending and increased revenues were poised to take effect at the end of 2012; collectively, these were referred to by some as the “fiscal cliff.” Had these policies taken effect, CBO projected that the ensuing fiscal contraction would have resulted in a recession in 2013. On January 2, 2013, the President signed H.R. 8, the American Taxpayer Relief Act of 2012 (ATRA, P.L. 112-240), which prevented most—but not all—of the fiscal cliff policies from going into effect. This Act was passed by the Senate on January 1, 2013 by a vote of 89-8, and by the House later that day, 257-167. Title VI of the Act extends several expiring provisions in the Medicare and Medicaid programs and makes other changes in federally funded health programs.
Provisions in Title VI of ATRA that will result in higher physician fee schedule payments include the override of the sustainable growth rate (SGR) update mechanism of the Medicare physician fee schedule that would have reduced payments had it taken effect, and the extensions of the physician work geographic adjustment. Other provisions preserved some Medicare hospital payments by extending adjustments for low-volume hospitals and the Medicare-dependent hospital program. Sections that addressed Medicare managed care include the extension of the Medicare Advantage special needs plans and reasonable cost contracts. Medicare beneficiaries will continue to have access to the exceptions process for outpatient therapy limits and outreach and assistance programs for low-income beneficiaries. Other health programs extended by the ATRA include the qualifying individual program, the transitional medical assistance program, the Medicaid and the State Children’s Health Insurance Program (CHIP) express lane option, familyto-family health information centers, and special diabetes programs for Type I diabetes and for American Indians and Alaska Natives.
The Congressional Budget Office (CBO) estimates that the health provisions in H.R. 8 will result in a net increase in direct spending of $800 million over the ten-year period from FY2013 through FY2022. The physician payment override (“doc fix”) and the various health-related extensions cumulatively add an estimated $29.3 billion to direct spending. CBO estimates that the other health provisions cumulatively result in offsets of all but $800 million as a result of the direct effects of the provisions and the interactions between provisions. While some sections of ATRA make changes to federal health programs that result in savings to the federal budget, other sections addressing federal health care programs have little or no impact on direct spending in the federal budget.
New from the GAO
New GAO Reports
Source: Government Accountability Office
PRIVATE HEALTH INSURANCE
Expiration of the Health Coverage Tax Credit Will Affect Participants’ Costs and Coverage Choices as Health Reform Provisions Are Implemented
GAO-13-147, Dec 28, 2012
The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis
Source: Kaiser Family Foundation
A central goal of the Patient Protection and Affordable Care Act (ACA) is to significantly reduce the number of uninsured by providing a continuum of affordable coverage options through Medicaid and new Health Insurance Exchanges. Following the June 2012 Supreme Court decision, states face a decision about whether to adopt the Medicaid expansion. These decisions will have enormous consequences for health coverage for the low-income population.
This analysis uses the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM) to provide national as well as state-by-state estimates of the impact of ACA on federal and state Medicaid costs, Medicaid enrollment, and the number of uninsured. The analysis shows that the impact of the ACA Medicaid expansion will vary across states based on current coverage levels and the number of uninsured. This analysis shows that by implementing the Medicaid expansion with other provisions of the ACA, states could significantly reduce the number of uninsured. Overall state costs of implementing the Medicaid expansion would be modest compared to increases in federal funds, and some states are likely to see small net budget savings.
CRS — Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act (ACA): Issues for Congress
Source: Congressional Research Service (via OpenCRS)
The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) requires certain health insurers to provide rebates to their customers for each year that the insurers do not meet a set financial target called a medical loss ratio (MLR). At its most basic, an MLR measures the share of a health care premium dollar spent on medical benefits, as opposed to company expenses such as overhead or profits. For example, if total premiums collected are $100,000, and $85,000 is spent on medical care, the MLR would be 85%. The ACA sets the minimum required MLR at 80% for the individual and small group markets and at 85% for the large group market. In general, the higher the MLR, the more value a policyholder receives for his or her premium payment. Congress imposed the MLR in an effort to provide “greater transparency and accountability around the expenditures made by health insurers and to help bring down the cost of health care.” Insurers that fail to meet these minimum standards must provide rebates to policyholders.
The Department of Health and Human Services (HHS), with input from state insurance commissioners who are the main regulators of health insurance, issued rules for implementing the provisions. These rules provided greater details for calculating the MLR and issuing rebate payments. ACA allows companies to include quality improvements along with medical benefits when calculating the MLR. In addition, state and local taxes and some licensing fees are subtracted (i.e., disregarded) from expenses in the MLR formula. ACA’s requirements are different from those imposed by state laws, which generally compare only medical claims to premiums. Though a number of states have their own MLRs, the ACA is now the minimum standard that must be met nationwide by certain health insurers. About 12.8 million U.S. consumers were due more than $1.1 billion in ACA MLR rebate payments in August 2012, for an average award of $151 per qualifying household. Employers or insurers can provide the rebates, which are based on activity in 2011, via a check, an electronic deposit in a bank account, a reduction in future insurance premiums in the amount of the rebate, or by spending the funds for the benefit of employees. About 66.7 million people were insured by covered companies that met or exceeded MLR standards for 2011, and will not receive rebates.
The MLR is based on the aggregate performance of a health plan, not individual policy history. Even if a beneficiary had no medical claims during a given year, he or she would not receive a rebate if the broader plan met the MLR requirements. In addition, many Americans were enrolled in health plans that were not covered by the ACA MLR provisions in 2011. The ACA MLR provisions cover only fully funded health plans, which are plans where insurance companies assume the full risk for medical expenses incurred. The requirements do not extend to self-funded plans, which are health care plans offered by businesses in which the employer assumes the risk for, and pays for, medical care. Non-profit insurers and some Medicare Advantage plans were not covered by the ACA MLR standards in 2012, though the MLR provisions will be phased in during 2013 and 2014, respectively. In addition, some states won special exceptions for individual insurance policies, based on an HHS determination that meeting the MLR requirement would harm a state’s insurance market.
Several issues have been raised about the MLR provisions since the ACA was enacted. These include considerations regarding the treatment of insurance agent and broker bonuses and commissions, the impact of the MLR on insurers that provide high deductible plans, and special rules for non-profit health insurers.
After The Election: A Consumer’s Guide To The Health Law
After The Election: A Consumer’s Guide To The Health Law
Source: Kaiser Family Foundation
Now that President Barack Obama has won a second term, the Affordable Care Act is back on a fast track.
Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.
While some of the key features don’t kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.
Here’s a primer on parts of the law already up and running, what’s to come and ways that provisions could still be altered.
Hat tip: PW
Medicaid Today; Preparing for Tomorrow — A Look at State Medicaid Program Spending, Enrollment and Policy Trends Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2012 and 2013
Source: Kaiser Family Foundation
After the worst economic downturn since the Great Depression, state policy makers were finally beginning to see signs of economic recovery at the end of state fiscal year (FY) 2012 and heading into FY 2013. Growth in total Medicaid spending and enrollment slowed substantially in FY 2012 as the economy began to improve. Relatively slow spending and enrollment growth are expected to continue in FY 2013.
Cost pressure and cost containment were still dominant themes, but states were also able to consider program changes, payment and delivery system reforms and continue efforts to re-orient long-term care programs to community-based care models. Eligibility rules for Medicaid remained stable due to the maintenance of eligibility (MOE) protections that were part of health reform legislation, and a number of states adopted targeted eligibility expansions or simplified enrollment procedures.
States are also preparing for the new role for Medicaid in the implementation of the Affordable Care Act (ACA). Under the June 2012 Supreme Court ruling, the Secretary’s authority to enforce the ACA Medicaid expansion requirement is limited, and state policy makers will decide whether or when to implement the Medicaid expansion.
The findings in this report are drawn from the 12th consecutive year of the Kaiser Commission on Medicaid and the Uninsured (KCMU) and Health Management Associates (HMA) budget survey of Medicaid officials in all 50 states and the District of Columbia. This survey reports on trends in Medicaid spending, enrollment and policy initiatives for FY 2012 and FY 2013. The report describes policy changes in reimbursement, eligibility, benefits, delivery systems and long-term care, as well as detailed appendices with state-by-state information, and a more in-depth look through four state-specific case studies of the Medicaid budget and policy decisions in Massachusetts, Ohio, Oregon and Texas.
CRS — What is “Small”? Definition of Small Business in the Patient Protection and Affordable Care Act
What is "Small"? Definition of Small Business in the Patient Protection and Affordable Care Act (PDF)
Source: Congressional Research Service (via Rep. Michelle Bachman)
This memorandum provides a brief description of the ACA provisions that apply to employers, focusing on how each provision defines"small" and affects employers of different sizes. The memorandum also identifies what definition of employee is used. Three types of provisions are described: employer responsibilities regarding health insurance coverage; employer reporting requirements; and other employer incentives to provide health insurance coverage.
Plan Participation in Health Insurance Exchanges: Implications for Competition and Choice
Plan Participation in Health Insurance Exchanges: Implications for Competition and Choice
Source: Urban Institute
This brief examines the conditions under which competition in health insurance exchanges is likely to be effective in placing downward pressure on insurance premiums. We conclude that areas with a single dominant insurer or a dominant hospital system are less likely to experience effective competition. In markets in which there are several insurers with significant market share and no dominant hospital system, the result could be limited or tiered network products that could successfully constrain the cost of premiums. Participation of existing Medicaid plans may also increase effective competition in health insurance exchanges.
CRS — NFIB v. Sebelius: Constitutionality of the Individual Mandate
NFIB v. Sebelius: Constitutionality of the Individual Mandate (PDF)
Source: Congressional Research Service (via Federation of American Scientists)
In one of the most highly anticipated decisions in recent years, the Supreme Court released its ruling regarding the constitutionality of the Affordable Care Act (ACA) in June 2012. In NFIB v. Sebelius, the Court largely affirmed the constitutionality of ACA, including its individual mandate provision. In a move that was unexpected to many, the Court upheld the mandate as a valid exercise of Congress’s taxing power, but not its Commerce Clause power.
First, Chief Justice Roberts, in a controlling opinion, found that the Commerce Clause does not provide Congress with the authority to enact the individual mandate. While the Chief Justice acknowledged that Congress’s authority to regulate interstate commerce is quite broad, he also pointed out that Congress had never attempted to use this power to make individuals buy an undesired product. The Chief Justice further noted that the language of the Clause (i.e., the power to regulate interstate commerce) reflects the idea that there must be something to regulate in the first place (i.e., some type of “activity”). The problem with the individual mandate, as indicated by the Chief Justice, is that it “does not regulate existing commercial activity. It instead compels individuals to become active in commerce by purchasing a product on the ground that their failure to do so affects interstate commerce.” The Chief Justice also noted that if the mandate were permissible under the Commerce Clause, a mandatory purchase could be permitted to solve almost any problem, thus agreeing with those who had raised concerns about a lack of a limiting principle—the idea that if Congress could require the purchase of health insurance, it could require Americans to purchase anything. While no other Justice joined the opinion of Chief Justice Roberts with respect to the Commerce Clause analysis, four Justices issued a dissenting opinion that reached the same conclusion based on somewhat similar reasoning.
The Chief Justice then found the mandate provision to be a valid exercise of Congress’s taxing power. For this portion of the opinion, Chief Justice Roberts was joined by Justices Ginsburg, Breyer, Sotomayor, and Kagan. The key question here was whether the mandate provision was a tax or penalty. The Court used a functional approach to find the provision was in fact a tax, looking at its substance and application, rather than any statutory labels (which used the term “penalty”). The Court rejected the argument that the provision was actually a regulatory penalty, and therefore outside the scope of the taxing power, because it was not prohibitory, had no scienter requirement, and would be collected just like any other tax by the IRS. The provision’s obvious regulatory purpose was not a significant factor, with the Court noting that it is common for taxes to be intended to influence behavior. Further, the Court found the provision did not have to be read as making the failure to buy health insurance unlawful. Finally, the Court found the mandate provision, while a tax, was not a “direct tax” and therefore was not subject to the Constitution’s requirement that direct taxes be apportioned among the states based on population.
It should be noted that the Supreme Court also rendered a decision on the constitutionality of the ACA’s expansion of the Medicaid program. For a discussion of the Supreme Court’s decision on the Medicaid expansion, see CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth R. Thomas.
Provider 2020: Strategies for strategic differentiation in an uncertain environment
Provider 2020: Strategies for strategic differentiation in an uncertain environment
Source: Deloitte
A number of factors are converging to make the next decade likely one of the most tumultuous in the history of the health care industry. While it may seem premature or even risky to begin planning for a future that is uncertain, the greater risk is failing to take decisive action now.
“Provider 2020: Strategies for strategic differentiation in an uncertain environment” takes a closer look at a strategic response to the path forward. In this article, Deloitte reviews:
- Potential strategic destinations for hospitals and health systems
- The evolving journey of strategic differentiation
- “False positives” in the current market
- Where to start: Selecting the suitable path for strategic differentiation
National Federation of Independent Business v. Sebelius: Five Takes
National Federation of Independent Business v. Sebelius: Five Takes
Source: Social Science Research Network
In this article, following our now-famous “Five Takes” format, we will look at some possible meanings and implications of the Supreme Court’s decision.
We first consider possible analogies between NFIB and two other famous cases whose opinions are held out as deftly straddling the line between principle and prudence: Marbury v. Madison and the Bakke case (Takes One and Two). Takes Three and Four examine the opinion though the lens of constitutional theory. We consider whether the decision, Chief Justice Roberts’s opinion especially, served what Charles Black called the Court’s “legitimating” function, quelling doubts about the Act’s constitutionality and, thus, its legitimacy. We further consider whether, in ultimately upholding the Act despite its relative unpopularity, Chief Justice Roberts’s opinion could be seen as an example of judicial restraint a la James Bradley Thayer. Finally, in Take Five, we consider that the peculiar construction of the opinion handed the Administration a somewhat Pyrrhic victory while laying the foundation for robust judicially-enforced limits on congressional power. A brief conclusion follows.
New High Interest GAO Report — Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage
New GAO Report
Source: Government Accountability Office
Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage. GAO-12-768, July 13.
http://www.gao.gov/products/GAO-12-768
Highlights – http://www.gao.gov/assets/600/592412.pdf
CBO — Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act
Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act
Source: Congressional Budget Office
CBO and the staff of the Joint Committee on Taxation (JCT) have estimated the direct spending and revenue effects of H.R. 6079, the Repeal of Obamacare Act, as passed by the House of Representatives on July 11, 2012. H.R. 6079 would repeal the Affordable Care Act (ACA), with the exception of one subsection that has no budgetary effect. This estimate reflects the spending and revenue projections in CBO’s March 2012 baseline as adjusted to take into account the effects of the recent Supreme Court decision regarding the ACA.
For various reasons discussed in the report, the estimated budgetary effects of repealing the ACA by enacting H.R. 6079 are close to, but not equivalent to, an estimate of the budgetary effects of the ACA with the signs reversed.
