A not-for-profit health and tax policy research organization

Testimony before the

United States House of Representatives
Committee on the Budget

Rep. Diane Black, Interim Chair

Rep. John Yarmuth, Ranking Member

Hearing on

THE FAILURES OF OBAMACARE:

HARMFUL EFFECTS AND BROKEN PROMISES

January 24, 2017

Testimony presented by
Grace-Marie Turner
President, Galen Institute

P.O. Box 320010 • Alexandria, VA 22320 • Phone 703-299-8900 • www.galen.org

 “THE FAILURES OF OBAMACARE:
HARMFUL EFFECTS AND BROKEN PROMISES”

Committee on the Budget

January 24, 2017

Grace-Marie Turner, Galen Institute

Chairman Black, Ranking Member Yarmuth, and members of the committee, thank you for the
opportunity to testify today on the consequences of the Affordable Care Act on American
families, small businesses, workers, and young people.

My name is Grace-Marie Turner, and I am president of the Galen Institute, a non-profit research
organization focusing on patient-centered health policy reform. I also served as an appointee to
the Medicaid Commission from 2005-2006, as a member of the Advisory Board of the Agency
for Healthcare Research and Quality from 2005 to 2007, and as a congressional appointee to the
Long Term Care Commission in 2013.

While millions of people have received health coverage through the Affordable Care Act, many
millions more have felt the personal harm it has imposed on them and their families. I know that
you and many other members of this body, including Speaker Ryan, have provided assurances
that repeal and replace measures will protect the people who are receiving coverage now under
the health law while building a bridge to new coverage that will protect others from the damage
that it has done and is doing to their pocketbooks and their access to medical care.

The costs of health insurance are crippling many families’ finances, including forcing them to
work extra jobs. An Uber driver who lives in Maryland told me last week that he is working this
second job so he can pay for health insurance. The premium for the policy for himself, his wife,
and one child is $1,200 a month. He must spend hours away from them every week to meet his
obligation to provide coverage. I hear similar stories repeatedly from people across the country.
While many millions are covered, millions more are pleading for relief.

The impact on young people

Young people face many daunting challenges in getting started in the workforce in our changing
economy. Many of those who were fortunate enough to attend college struggle to make their
student loan payments. Lackluster economic growth has made it extremely hard for them and for
far too many others to find that first real job.

One of the ways that the Affordable Care Act tried to help them was by allowing adult children
to stay on their parents’ policies until age 26. But this provision is not free. “We find evidence
that employees who were most affected by the mandate, namely employees at large firms, saw
wage reductions of approximately $1,200 per year,” according to Gopi Shah Goda and Jay

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Bhattacharya of Stanford and Monica Farid of Harvard. As this new wave of young adults was
added to their parent’s existing job-based policies, the cost of coverage inevitably climbed.
Companies responded by scaling back cash wages as a share of overall compensation. The study
found that the costs of the 26-year-old mandate weren’t “only borne by parents of eligible
children or parents more generally.” The costs were spread to each worker—not just the
dependents’ parents.1

This was a very popular provision, but it has been one of the factors flattening cash wages and
driving up the cost of coverage for tens of millions of workers at American firms.

The ACA makes a direct hit on young people in two important ways: First, young people
purchasing individual policies in or out of the exchanges are required to pay much more for their
policies than their actuarially-expected costs because of the law’s required 3:1 age rating band.
Forcing the young to pay more drives costs up for everyone.

The average 64-year-old consumes six times as much health care, in dollar value, as the average
21-year-old.2 Under the ACA’s age-rating requirements, insurers cannot charge their oldest
policyholders more than three times the price they charge their youngest customers. If every
customer were to remain in the insurance market, this would have the net effect of increasing
premiums for 21-year-olds by 75%, and reducing them for 64-year-olds by 13%.3

However, if half of the 21-year-olds drop out of the market because they don’t see the insurance
as a good value, this drives premiums up for everyone, including the 64-year-olds who were
supposed to benefit from the rule.

In theory, the individual mandate penalty should force these younger individuals to purchase
health coverage, even if that coverage is more expensive than their actual health care
consumption. In reality, however, the ACA’s individual mandate is relatively weak, often
representing a fraction of the cost of ACA-based coverage.

Many young people are opting to pay the individual mandate penalty—or get an exemption—
rather than enroll in health insurance. This has destabilized the exchange pools, which
desperately need more young people to enroll to balance out the disproportionate number of
older, sicker people.

The ACA’s employer mandate—requiring employers with more than 50 workers to sponsor
health coverage for their workers—contributes to the difficulty young people have in finding the
entry-level jobs that allow them to get the experience they need to get moving with their
professions and careers. Businesses are automating the jobs out of existence, hiring only part-
time workers exempt from the mandate, deciding not to expand their businesses, or just doing
without the help they need. Economist Ben Casselman of FiveThirtyEight found “the evidence
suggests [the ACA] has led some employers to limit the hours of workers who were already part-
time, effectively giving a pay cut to some of the most vulnerable Americans.”4 Jed Graham of
Investor’s Business Daily has an extensive catalogue of hours cut and jobs lost that employers
attribute to ObamaCare employer mandate.5

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Young people need strong economic growth to boost the economy so it can create more jobs.
But they also need the federal government to lighten the regulatory burden that makes it so
difficult for employers to hire entry-level lower-skilled workers.

The impact on families

The ACA imposes tax penalties on Americans who do not purchase compliant health coverage.
IRS reports that for the 2015 tax year, 6.5 million people paid $3 billion in penalties.6 Another
12.7 million claimed an exemption from the individual mandate penalty.7 These 19 million
people clearly are saying the health insurance the federal government is requiring them to
purchase is too expensive or not a good value for the cost they are required to pay. Far too many
of them are the younger, healthier people that we most need in the insurance pools to make them
solvent.

A report in Modern Healthcare shows some of the problems that the ACA’s attempted micro-
management of health insurance have caused:8

If HHS Secretary Sylvia Mathews Burwell was listening to NPR's "Morning Edition" on
Tuesday, the first day of 2017 open enrollment, she must have felt sick.

On the broadcast, Will Denecke, a self-employed urban planning consultant in Portland,

Ore., said he planned to skip buying health insurance for 2017 because the premium had
shot up to $930 a month. Instead, the 63-year-old man said if he developed a medical
issue sometime during the year, he would go to the Affordable Care Act marketplace and
buy a plan outside the open-enrollment window, which he's aware he's not supposed to
do.

He said the ACA rules sharply limiting such midyear enrollment are easy to get around.
Last time he simply claimed a change of income. “I've done it before, and my broker
helped me,” he boasted, while admitting, “I know that undermines the economics and
premise of the ACA."

That's precisely the type of consumer gaming that's producing heartburn for the Obama
administration. Insurers complain it's causing them serious financial losses in the ACA-
regulated individual markets. Such abuses are one factor prompting widespread calls for
federal policy changes to stabilize the exchanges.

Meanwhile, because of the sharply rising 2017 premiums, healthier consumers

increasingly are gravitating to cheaper short-term health plans that don't meet ACA rules.
The growth of such plans, which as many as 1 million people have purchased, could
further undercut the ACA markets.

Brokers say this trend reflects the turmoil in the individual market. “I've got clients
saying, 'The prices are nuts and I won't pay it, I'll pay the penalty,' ” said Lisa
Lettenmaier, a broker who owns the HealthSource Northwest brokerage in Portland and

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 who spoke during a short break in the hectic first day of open enrollment.

Enrollment in the exchanges has been far below expectations. The Congressional Budget Office
originally estimated that 21 million people would be enrolled in exchange coverage by 2016. As
of June 2016, only 10.5 million were enrolled.9 That is 2.2 million fewer than had selected a
plan by the end of open enrollment on February 1.10

For those purchasing coverage in the ACA exchanges, premiums went up an average of 25%,11
with people in many other states experiencing much higher increases—averaging greater than
50% in Illinois, Montana, Oklahoma, and Tennessee, for example, and 116% in Arizona.

To keep premium prices from soaring further, health plans are narrowing their networks of
providers and hospitals. Avalere found that networks in ACA exchange plans have 34% fewer
providers compared to commercial plans.12 A report in Modern Healthcare found that 70% of
plans sold on the exchanges in 2014 consisted of narrow networks,13 and the number is getting
higher.14

According to a report in USA Today:15

Loralea Grey, whose husband is self employed, says they are living a "middle-class
nightmare" because of the law. They grew used to the necessary sacrifices to afford the
premiums and out-of-pocket costs for their "catastrophic" insurance before the ACA, she
says. This year they were facing a premium increase of nearly 40% with a $7,000
deductible per family member. They've decided they can't scrimp anymore to afford plans
through the ACA exchange.

"How is this possible or allowable?," she asks. "When I contacted the Oregon insurance
commissioner, I received a response back telling me I should feel free to shop around; as
if I wasn’t smart enough to have already done that?"

... In North Carolina, the cheapest option with a "decent network" of doctors and
hospitals for Jim Harrison's 61-year-old wife would cost $1,421 a month with a $7,150
deductible. (He is on Medicare.) Because he is retired and that isn't affordable, the family
got a hardship exemption from the mandate to have insurance.

"So against our better judgment, she is going to go without health insurance next year ...
but we put all of our retirement assets at risk should something catastrophic happen," he
says, "I never thought we would be in this situation."

Consumers faced dilemmas with rising premiums and fewer choices. The Daily Signal reports
about the experience of Rochelle Bird, a financial adviser from Overland Park, Kansas:16

Bird is one of roughly 10 million Americans who doesn’t receive insurance from an
employer—she’s self-employed—and also doesn’t qualify for a subsidy. So when
insurers announced double-digit premium increases for 2017, she prepared to pay full
price for coverage purchased in the individual market.

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 And that wasn’t it.

Coventry Health Care sent Bird a notice last month saying it would cancel her policy at
the end of the year.

On the first day of open enrollment, the Overland Park resident selected a new plan
through Blue Cross Blue Shield of Kansas City, one that is only $50 more than her old
policy.

But though Bird’s premiums increased minimally compared to others across the country,
her deductible is higher and she has less coverage than with her previous plan.

“I’m paying more for less,” she said.

Even with the higher premiums, insurers are facing losses on ACA policies that are driving many
out of the market. One-third of all U.S. counties will have just one insurer. In 2016, a total of
225 counties in the U.S. had only one insurer offering coverage, but that number more than
quadrupled to 1,022 in 2017.17 Thirty-three states have fewer insurers offering coverage on the
exchanges in 2017 than in 2016. Only one state, Virginia, gained insurers. Five states have only
one insurer, while 13 have just two. This is certainly not the competitive market that creators of
the ACA envisioned.

Again, The Daily Signal offers an example of a veterinarian whose premiums doubled over three
years while the quality of his coverage eroded:18

For the past 15 years, Warren Jones has had the same health insurance plan with Blue
Cross and Blue Shield of Kansas City.

But over the years, Jones, of Kansas City, Missouri, has watched the coverage offered in
his policy “erode” over time.

First, the company got rid of the dental and vision coverage he had.

Then, Jones’ deductible increased—to $2,500—for his plan alone.

But perhaps the most significant change for Jones, a veterinarian, has been the rising cost
of his monthly premiums.

In 2014, the year Obamacare took effect, Jones paid $318 in monthly premiums. In 2015,
the price went up to $394 per month, then to $491 for 2016.

For 2017, Blue Cross and Blue Shield of Kansas estimates that Jones will pay $716 each
month for his premiums—a 45.8 percent increase—according to a letter the insurer sent
him.

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 “You can’t keep doing this because people’s wages don’t increase by that amount,” Jones
told The Daily Signal. “Nobody’s wages are increasing, so it’s taking a bigger chunk of
the budget.”

Further, more than 800,000 people who were enrolled in ACA Co-op health plans in 18 states
lost their plans and were forced to find other coverage.19 American taxpayers spent $2.4 billion20
to finance these start-up, non-profit health plans, but they struggled from a lack of experienced
management that failed to match the price of their policies with the services their enrollees were
consuming. American families suffered as a result.

The law’s “essential health benefits” and the extensive regulatory interpretation by the Obama
administration contribute to the rising cost of insurance. Another contributor is the nearly two-
dozen new and higher taxes in the ACA totaling more than $1 trillion:21
o Individual mandate tax. A mandate that people buy government-directed health
coverage, with tax penalties for those who don’t. $43.3 billion in taxes.
o Employer mandate tax. A mandate that employers provide government-directed
health coverage, with tax penalties for those who don’t. $166.9 billion in taxes.
o Cadillac tax. A 40% excise tax on generous workplace health plans. $87.3 billion in
taxes.
o Medical device tax. A 2.3% tax on sales by manufacturers of medical devices and
equipment that will cost jobs and make medical care more expensive. $23.9 billion in
taxes.
o Health savings taxes. Tax increases on Flexible Spending Accounts and the purchase
of over-the-counter medicine, and increased tax penalties on Health Savings
Accounts and Archer Medical Savings Accounts. $74.4 billion in taxes.
o Health insurance tax. An annual tax on health insurers that is passed on to
consumers. $142.2 billion in taxes
o Pharmaceutical tax. An annual tax on drug manufacturers that is passed on to
consumers. $29.6 billion in taxes

The ACA has failed Americans who were promised more choices of more affordable coverage in
the exchanges, but those outside the exchanges have felt the impact as well as they have been hit
with these taxes.

Former President Obama promised that the average American family would see its insurance
premiums fall by $2,500 a year, yet average annual family premiums in the employer-sponsored
market have soared by roughly $4,300 and now total more than $18,000 annually.22

Some of the ACA taxes were delayed for two years as Congress saw the impact they were
having on rising premiums. The Health Insurance Tax in particular is a direct sales tax on health
insurance that increases the premiums people pay. The HIT was delayed for only one year, and
it starts impacting small businesses as early as Feb. 1 of this year as they begin to renew their
coverage. It will be fully integrated into rates shortly after as insurers start solidifying 2018 rate
filings. Economist Doug Holtz-Eakin concluded this one tax will raise premiums for small
businesses and households by nearly $5,000 per family over a decade.23

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Impact on small businesses

Companies have struggled in trying to pay their workers a competitive wage while still making
enough of a profit margin to stay in business. Health insurance costs for small firms have risen
56% in the last decade.24 Worker wage increases have suffered as a result. Too much of the
money that employees could have seen as wage increases has been consumed by rising health
insurance costs instead. Workers also have seen their share of premium payments rising.
Provider networks have narrowed. And deductibles have been rising.

The SHOP exchanges were supposed to help small businesses. Small businesses had high hopes
for this program. The Obama administration’s Council of Economic Advisers said in July 2009
that it would reduce the burden on small business by allowing firms to choose among more plans
to provide better coverage at lower costs. That, coupled with the small business tax credit for
firms with lower average wages, would help balance their higher administrative and other costs
compared to larger firms.

It didn’t succeed. The tax credits were so complicated and the path to obtaining them so narrow
that the credits drew very limited interest and participation. The SHOP exchanges also failed to
provide a broader range of affordable and attractive choices of insurance for small businesses.

Instead, small businesses face continued premium increases, administrative burdens, and ever-
more-limited coverage options.

Businesses with more than 50 full-time workers that don’t meet ACA health coverage criteria are
subject to tax penalties of up to $3,000 per worker per year. Twenty-one percent of businesses
report that they have reduced the number of employees, wages, and benefits as a result of the
law.25 The “cost of health insurance” consistently is reported as their number one problem.

The federal government has not collected data on the impact of the ACA on the “opportunity
cost” of small business growth, but small business owners definitely see the impact. Here is a
report from The Daily Signal about Scott Womack, owner of about a dozen IHOP restaurants in
Indiana and Ohio:26

The IHOP in Terre Haute is located on South 3rd Street, just a few minutes from the
Interstate 70 interchange and a short drive from the Holiday Inn where we had stayed the
night before. As we sat in the back of the bustling restaurant waiting for Womack to
arrive, we ordered french toast, omelets and other IHOP specialties.

At the time, Womack employed about 1,000 people at his 12 restaurants. When the
Affordable Care Act became law on March 23, 2010, he had big plans for his franchise.
He had purchased a development agreement in 2006 that would expand the company to
14 new IHOP locations in Ohio…

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 “Let me state this bluntly,” Womack told lawmakers [in earlier testimony before
Congress], “this law will cost my company more money than we make.”

The cost of Obamacare’s mandates—Womack estimated it would be $7,000 to provide

health care coverage for each full-time employee—left him with few options: cut costs,
eliminate staff, reduce hours or convert workers to part-time status.

Four years later, facing the prospect of Obamacare’s employer mandate on Jan. 1, 2015,
Womack opted to sell his 16 IHOP restaurants last year to Romulus Restaurant Group.

Impact on vulnerable Americans

Research from ACA architect Jonathan Gruber and his coauthors,27 using data from the Census
Bureau, estimate that Medicaid “produced 63% of the gains [in coverage] that we identified” for
2014. Gruber et al found that much of this gain was attributable to the enrollment in Medicaid of
people who were eligible for the program under criteria that preceded the ACA’s Medicaid
expansion.

Mercatus Center economist Brian Blase concludes: “Dividing Gruber’s estimate of the
percentage gain in coverage of Medicaid enrollees who were eligible before the ACA by the
percentage gain in coverage attributable to Medicaid overall means that 70% of new Medicaid
enrollees in 2014 were eligible for the program under pre-ACA rules.”28

While there are many unintended consequences of the law, perhaps the most tragic is how it is
harming some of the most vulnerable on Medicaid.

Charles Blahous of the Mercatus Center concludes, based upon the latest CBO2930 uninsured
estimate that, “although ACA substantially increased Medicaid eligibility and federal funding, it
did not appreciably change the supply of health care services available through Medicaid.
Accordingly, the primary effect of the ACA’s Medicaid coverage expansion was to require the
most sympathetic and vulnerable Medicaid population (lowest-income enrollees, pregnant
women, children, etc.) to face more competition for health services from a marginally less
vulnerable population (childless adults of somewhat higher income).”31

Too many states have enthusiastically enrolled people in Medicaid but are failing to pay
providers enough to allow them to afford to see all of the Medicaid patients seeking
appointments. A Louisiana Medicaid recipient told The New York Times: 32

“My Medicaid card is useless for me right now. It’s a useless piece of plastic. I can’t
find an orthopedic surgeon or a pain management doctor who will accept Medicaid.”

The next chapter in advancing health reform

President Trump’s executive order of January 2033 directed all federal agencies “to minimize the
unwarranted economic and regulatory burdens” of the Affordable Care Act. While
administrative actions will be able to postpone or lighten the burden of the regulations in place,

8
only Congress can actually change the underlying law, not only to provide relief from the
existing rules but also to provide new opportunities to give people the option of more affordable
coverage and more choices of coverage that people and families want and need. I look forward
to working with you to develop those policies. Thank you for the opportunity to testify today,
and I look forward to your questions.

ENDNOTES
1
“ObamaCare’s $1,200 Pay Cut: The cost of insuring your 26-year-old is more than you thought,” The Wall Street
Journal, January 12, 2016. http://www.wsj.com/articles/obamacares-1-200-pay-cut-1452643649
2
Avik S.A. Roy, “Transcending ObamaCare. Achieving Truly Affordable, Patient-Centered, Near-Universal
Coverage.” Testimony before the United States Congress House Committee on Energy & Commerce
Subcommittee on Health, May 11, 2016. https://www.manhattan-institute.org/html/testimony-avik-roy-house-
energy-commerces-subcommittee-health-8865.html
3
Ibid.
4
Ben Casselman, “Yes, Some Companies Are Cutting Hours in Response to ‘Obamacare’,” FiveThirtyEight, January
13, 2015. https://fivethirtyeight.com/features/yes-some-companies-are-cutting-hours-in-response-to-obamacare/
5
Jed Graham, “Obamacare Employer Mandate: A List of Cuts to Work Hours, Jobs,” Investor’s Business Daily,
September 5, 2014. http://www.investors.com/politics/obamacare/obamacare-employer-mandate-a-list-of-cuts-
to-work-hours-jobs/
6
IRS Commissioner John Koskinen, letter to Members of Congress, Jan. 9, 2017.
https://www.irs.gov/pub/newsroom/commissionerletteracafilingseason.pdf
7
The IRS also reports that an additional 4.3 million people failed to “check the box” indicating whether they had
coverage. The agency is analyzing these cases to determine their status.
8
Harris Meyer, “As enrollment opens, some consumers look for loopholes to avoid higher premiums,” Modern
Healthcare, November 2, 2016. http://www.modernhealthcare.com/article/20161102/BLOG/161109980/blog-as-
enrollment-opens-some-consumers-look-for-loopholes-to-avoid
9
Centers for Medicare and Medicaid Services, “First Half of 2016 Effectuated Enrollment Snapshot,” October 10,
2016. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-
19.html
10
Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation, “Health
Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report for the Period: November 1, 2015 –
February 1, 2016,” March 11, 2016. https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf
11
Health Plan Choice and Premiums in the 2017 Health Insurance Marketplace, Office of the Assistant Secretary for
Planning and Evaluation, 24 October 2016.
https://aspe.hhs.gov/sites/default/files/pdf/212721/2017MarketplaceLandscapeBrief.pdf

12
Avalere, Exchange Plans Include 34 Percent Fewer Providers than the Average for Commercial Plans. July 15,
2015: http://avalere.com/expertise/managed-care/insights/exchange-plans-include-34-percent-fewer-providers-

9
than-the-average-for-comm
13
Bob Herman, Network Squeeze: Controversies Continue Over Narrow Health Plans, Modern Healthcare, March
28, 2015:
http://www.modernhealthcare.com/article/20150328/MAGAZINE/303289988
14
2017 exchange market: Plan type trends,” McKinsey & Co., November 2016:
http://healthcare.mckinsey.com/2017-exchange-market-emerging-plan-type-trends
15
Jayne O’Donnell, “High health insurance costs prompt tough choices,” USA Today, Nov. 20,
2016. http://www.usatoday.com/story/news/politics/2016/11/20/high-health-insurance-costs-prompt-tough-
choices/93978956/
16
Melissa Quinn, “Meet 2 Hurting Americans Who Are Ready for Congress to Repeal Obamacare,” The Daily Signal,
November 29, 2016. http://dailysignal.com/2016/11/29/meet-2-hurting-americans-who-are-ready-for-congress-
to-repeal-obamacare/
17
Kaiser Family Foundation, “Insurer Participation in the 2017 Individual Marketplace,” December 2016.
https://public.tableau.com/profile/kaiser.family.foundation#!/vizhome/InsurerParticipationinthe2017IndividualM
arketplace/2017InsurerParticipation
18
Melissa Quinn, “In 3 Years, His Insurance Premiums Double as Options Decline Under Obamacare,” The Daily
Signal, October 17, 2016. http://dailysignal.com/2016/10/17/in-3-years-his-insurance-premiums-double-as-
options-decline-under-obamacare/
19
Author calculations based upon report from the U.S. Government Accountability Office, “Federal Oversight,
Premiums, and Enrollment for Consumer Operated and Oriented Plans in 2015,” March, 2016.
http://www.gao.gov/assets/680/675742.pdf
20
The amounts awarded represent the total funding that CMS agreed to provide to the CO-OPs. Ibid.
21
Andrew Lundeen, “Obamacare Tax Increases Will Impact Us All,” The Tax Foundation, March 5, 2013.
http://taxfoundation.org/blog/obamacare-tax-increases-will-impact-us-all
22
Kaiser Family Foundation, 2016 Employer Health Benefits Survey, September 14, 2016. http://kff.org/report-
section/ehbs- 2016-summary-of-findings/
23
Douglas Holtz-Eakin, “Higher Costs and the Affordable Care Act: The Case of the Premium Tax,” March 9, 2011,
American Action Forum. https://www.americanactionforum.org/wp-
content/uploads/sites/default/files/Case%20of%20the%20Premium%20Tax.pdf
24
National Federation of Independent Business, “Small Business Problems and Priorities,” August 2016,
http://www.nfib.com/assets/NFIB-Problems-and-Priorities-2016.pdf
25
Federal Reserve Bank of New York, “Supplemental Survey Report: Firms Assess Effects of Affordable Care Act,”
August 2016.
https://www.newyorkfed.org/medialibrary/media/survey/business_leaders/2016/2016_08supplemental.pdf?la=e
n
26
Rob Bluey, “Obamacare a Factor in IHOP Owner’s Decision to Sell His 16 Restaurants,” The Daily Signal, March
22, 2017. http://dailysignal.com/2015/03/22/this-longtime-ihop-owner-sold-his-restaurants-because-of-
obamacare/

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27
Molly Frean, B.A., Jonathan Gruber, Ph.D., and Benjamin D. Sommers, M.D., Ph.D., “Disentangling the ACA’s
Coverage Effects—Lessons for Policymakers,” The New England Journal of Medicine, October 27, 2016.
www.nejm.org/doi/pdf/10.1056/NEJMp1609016
28
Brian Blase, “New Gruber Study Raises Major Questions About Obamacare's Medicaid Expansion,” November 27,
2016, Forbes. http://www.forbes.com/sites/theapothecary/2016/11/27/new-gruber-study-raises-major-
questions-about-obamacares-medicaid-expansion/#78bfa913c936
29
Congressional Budget Office, “How Repealing Portions of the Affordable Care Act Would Affect Health Insurance
Coverage and Premiums,” January, 2017. https://www.cbo.gov/sites/default/files/115th-congress-2017-
2018/reports/52371-coverageandpremiums.pdf
30
For analyses of the limitations of the CBO’s estimate of the impact of partial repeal of the ACA, see:
Charles Blahous, “What CBO Analysis of Partial ACA Repeal Really Means,” e21, January 17, 2017.
https://www.mercatus.org/commentary/what-cbo-analysis-partial-aca-repeal-really-means;
Avik Roy, “Four Critical Problems With The CBO’s Latest Obamacare Repeal Estimate,” January 17, 2017, Forbes.
http://www.forbes.com/sites/theapothecary/2017/01/17/four-critical-problems-with-the-cbos-latest-obamacare-
repeal-estimates/#17e5ff678627; and
Chris Jacobs, “Three Points CBO Omitted from Its Report on Obamacare Repeal,” January 17, 2017, Chris Jacobs on
Health. http://www.chrisjacobshc.com/2017/01/17/three-points-cbo-omitted-from-its-report-on-obamacare-
repeal/
31
Charles Blahous, “What CBO Analysis of Partial ACA Repeal Really Means,” e21, January 17, 2017.
https://www.mercatus.org/commentary/what-cbo-analysis-partial-aca-repeal-really-means
w
32
Robert Pear, “Cuts Leave Patients with Medicaid Cards, but No Specialist to See,” April 2, 2011, The New York
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Executive Order, “Minimizing The Economic Burden of The Patient Protection And Affordable Care Act Pending
Repeal,” The White House, January 20, 2017. http://www.cnn.com/2017/01/20/politics/trump-obamacare-
executive-order/

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