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"In addition, the number of employers who offer health insurance has declined and costs for employer-paid health insurance are rising: from 2001 to 2007, premiums for family coverage increased 78%, while wages rose 19% and prices rose 17%, according to the Kaiser Family Foundation.[16] Even for those who are employed, the private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes — 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.[17] However, a study published by the Kaiser Family Foundation in 2008 found that the typical large employer preferred provider organization (PPO) plan in 2007 was more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option.[18] One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcys involved medical bills,[19]although other sources dispute this.[20]

There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance.[21][22] More broadly, estimates of the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year.[23] A study of the effects of the Massachusetts universal health care law (which took effect in 2006) found a 3% drop in mortality among people 20–64 years old - 1 death per 830 people with insurance. Other studies, just as those examining the randomized distribution of Medicaid insurance to low-income people in Oregon in 2008, found no change in death rate.[24]"

The lack of accessibility and rate of uninsured has been a primary motivation in the reform of the US healthcare system, and many different explanations have been proposed in the reasons for low insurance rates and to remedy them. One critique and motivation for healthcare reform has been the development of the Medical–industrial complex. This relates to moral arguments for health care reform, framing healthcare as a social good, one that is fundamentally immoral to deny to people based on economic status. The motivation behind healthcare reform in response to the medical-industrial complex also stems from issues of social inequity, promotion of medicine over preventative care. The medical-industrial complex, defined as a network of health insurance companies, pharmaceutical companies, and the like, plays a role in the complexity of the US insurance market and a fine line between government and industry within it. Likewise, critiques of insurance markets being conducted under a capitalistic, free-market model also include that medical solutions, as opposed to preventative healthcare measures, are promoted to maintain this medical-industrial complex. Arguments for a market-based approach to health insurance include the Grossman model, which is based on an ideal competitive model, but others have critiqued this, arguing that fundamentally, this means that people in higher socioeconomic levels will receive a better quality of healthcare.

"After campaigning on the promise of health care reform, President Barack Obama gave a speech in March 2010 at a rally in Pennsylvania explaining the necessity of health insurance reform and calling on Congress to hold a final up or down vote on reform.[54] The result of his efforts was the Patient Protection and Affordable Care Act. Because Obama's party did not have a filibuster-proof majority in the Senate, the law was amended by the Health Care and Education Reconciliation Act of 2010 using the reconciliation process in which debate in the Senate is limited and the filibuster is therefore not permitted.

The legislation remains controversial,[55][56][57] with some states challenging it in federal court[58] and opposition from some voters.[59] In June 2012, in a 5–4 decision, the U.S. Supreme Court found major portions of the law to be constitutional.[60] However, the law continues to face legal challenges. The latest attempt at reversing the Affordable Care Act occurred during the Government Shutdown on October 1, 2013. Government officials that oppose the ACA tried to make approval of a bill to reopen the government contingent on the demise of the ACA. This attempt met with failure and the government reopened on November 16, 2013.[61]

Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts

As a result of the law, insurance companies can no longer charge members based on gender, burdening men with the health care costs of women. A study by the National Institutes of Health reported that the lifetime per capita expenditure at birth, using year 2000 dollars, showed a large difference between health care costs of females ($361,192) and males ($268,679). A large portion of this cost difference is in the shorter lifespan of men, but even after adjustment for age (assume men live as long as women), there still is a 20% difference in lifetime health care expenditures.[62]

The act's provisions become effective over time. The most significant changes, particularly affecting the availability and terms of insurance become effective January 1, 2014. These include an expansion of Medicaid (at the option of each state) to those without dependent children and subsidized healthcare exchanges. Changes which occur earlier include allowing dependents to remain on their plan until 26, limitations on rescission (dropping insureds when they get sick), removal of lifetime coverage limits, mandates that insurers fully cover certain preventative services, high-risk pools for uninsureds, tax credits for businesses to provide insurance to employees, an insurance company rate review program, and minimum medical loss ratios.[3]

The law creates the Patient-Centered Outcomes Research Institute to study comparative effectiveness research funded by a fee on insurers per covered life (starting at $1, increasing to $2 and thereafter adjusted according to an index[63]). It also allowed the FDA to approve generic biologic drugs and specifically allows for 12 years of exclusive use for newly developed biologic drugs.

In addition, the law explores some programs intended to increase incentives to provide quality and collaborative care, such as accountable care organizations. The Center for Medicare and Medicaid Innovation was created to fund pilot programs which may reduce costs;[64] the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.[65] The law also requires for reduced Medicare reimbursements for hospitals with excess readmissions and eventually ties physician Medicare reimbursements to quality of care metrics.

The law is also designed to complement the 2009 HITECH Act which encourages the "meaningful use" of electronic health records; for example, the law directs the government to make use of these records for analyzing healthcare provider quality.[66]"

The Affordable Care Act also aims to promote access to preventative healthcare. Through providing access to screenings for diseases like breast cancer, promoting health in the workplace, and community preventative health, the Affordable Care Act contains sections that advance and promote preventative health initiatives.