Presentation at the Fifth Biennial Conference of the American Society of Health Economists, by Allison Percy, Health, Retirement, and Long-Term Analysis Division
Presentation by James Baumgardner, Ph.D., Deputy Assistant Director Health, Retirement, and Long-Term Analysis Division, CBO, to the 30th International Congress of Actuaries on April 4, 2014
This presentation provides information published in Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget (June 2012), www.cbo.gov/publication/43319
Presentation by James Baumgardner, Ph.D., Deputy Assistant Director Health, Retirement, and Long-Term Analysis Division, CBO, to the 30th International Congress of Actuaries on April 4, 2014
This presentation provides information published in Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget (June 2012), www.cbo.gov/publication/43319
Presentation by Keith Hall, CBO Director, to the National Association for Business Economics.
In fiscal year 2016, for the first time since 2009, the federal budget deficit increased in relation to the nation’s economic output. The Congressional Budget Office projects that over the next decade, if current laws remained generally unchanged, budget deficits would eventually follow an upward trajectory—the result of strong growth in spending for retirement and health care programs targeted to older people and rising interest payments on the government’s debt, accompanied by only modest growth in revenue collections. Those accumulating deficits would drive debt held by the public from its already high level up to its highest percentage of gross domestic product (GDP) since shortly after World War II.
CBO’s estimate of the deficit for 2017 has decreased since August 2016, when the agency issued its previous estimates, primarily because mandatory spending is expected to be lower than earlier anticipated. However, the current projection for the cumulative deficit for the 2017–2026 period is about the same as that reported in August.
CBO’s economic forecast—which underlies its budget projections—indicates that under current law, economic growth over the next two years would remain close to the modest rate observed since the end of the recession in 2009. Nevertheless, economic growth would continue to outpace growth in potential (maximum sustainable) GDP and thus continue to reduce the amount of underused resources, or slack, in the economy. The result would be increases in hiring, employment, and wages, along with upward pressure on inflation and interest rates. In the later part of the 10-year projection period, output growth would be constrained by a relatively slow increase in the nation’s supply of labor.
Presentation by Jessica S. Banthin, CBO’s Deputy Assistant Director for Health, Retirement, and Long-Term Analysis, to the Association for Public Policy Analysis and Management.
This presentation reviews CBO’s original and more recent projections of enrollment in health insurance policies through the exchanges established under the Affordable Care Act and the subsidies (including both premium tax credits and cost-sharing subsidies) provided to those enrollees, illustrating how the estimates have changed over time. CBO’s projections of 2014 exchange enrollment and subsidies are also compared with the actual enrollment and subsidies paid in that year.
Pharmaceutical Mergers Acquisitions in the U.SCapgemini
Since 2010, approximately 200 pharmaceutical and biotech deals have taken place per year in the United States. In 2014, only 182 major deals took place, lower than average (~190).
However, 2014 surpassed the combined value of deals from 2011-2013 ($178bn) and saw over $200bn in mergers and acquisitions, a 300% increase from the previous year.
The Chinese market is an obvious source of inspiration, talent, and opportunity for Australian businesses. But tackling such a complex market needs considerable context, insight, and cultural understanding.
At ThoughtWorks Live Australia 2016, Angela Ferguson and Hu Kai shared stories and learnings around the level of upfront preparation, commitment, and assessment needed to ensure the best chance of success in the Chinese market.
This presentation of the economic outlook for the coming decade highlights the key findings from CBO’s report The Budget and Economic Outlook: 2016 to 2026, which was released in January.
The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.
This presentation provides an overview of CBO and JCT’s current projections of health insurance coverage and how those projections have changed since March 2016, highlighting changes in Medicaid and CHIP enrollment and nongroup coverage.
Jessica Banthin, Deputy Assistant Director in CBO’s Health, Retirement, and Long-Term Analysis Division, will deliver this presentation on December 7, 2017, at the Inforum Outlook Conference at the University of Maryland.
This presentation provides a discussion of the theoretical and empirical basis for CBO’s estimates of the effect on health insurance coverage of repealing the individual mandate—which requires most people to have insurance or pay a penalty. CBO highlights and interprets new empirical evidence that may inform the size of that effect. CBO also poses unanswered questions for which the agency would like the discussants’ and health panel members’ insights.
Presentation by Alexandra Minicozzi, Unit Chief of Health Insurance Modeling in CBO’s Health, Retirement, and Long-Term Analysis Division, at a meeting of CBO’s Panel of Health Advisers.
The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.
This presentation provides an overview of CBO and JCT’s current baseline projections of health insurance coverage and how those projections have changed since March 2016, highlighting changes in Medicaid and CHIP enrollment and nongroup coverage.
Presentation by Jessica Banthin, Deputy Assistant Director in CBO’s Health, Retirement, and Long-Term Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
CBO discusses the theoretical and empirical basis for its estimates of the effect on health insurance coverage of repealing the individual mandate—which requires most people to have insurance or pay a penalty. These slides reprise material presented to CBO’s Panel of Health Advisers in September 2017, with the addition of updated estimates published earlier this month.
Presentation by Alexandra Minicozzi, Unit Chief of Health Insurance Modeling in CBO’s Health, Retirement, and Long-Term Analysis Division, at the annual meeting of the American Academy of Actuaries.
NCET Biz Cafe | Valerie Clark, Conundrum of US Healthcare | Sept 2017Archersan
Do you know how new health insurance laws will affect you and your family? Probably not. We totally get it.
In fact, our modern healthcare system has become so complicated, most people don’t understand it — even in its most basic forms.
But the September Tech Café will help, as Valerie Clark, president of insurance brokerage firm Clark & Associates, discusses “The Conundrum of the U.S. Healthcare System.”
Clark’s firm specializes in the development of creative health insurance plans for employer groups of all sizes, so she is perfectly equipped to lead this informative, frank and non-partisan discussion about the challenges and possible solutions to the serious issues that all Americans are facing today.
In this presentation, Clark will:
· Talk about how we got where we are with healthcare, where we’re going, and most importantly, how will it affect you and your family?
· Address major law changes and how they have affected access to and the cost of care over the past several decades.
· Explore the history and evolution of the U.S. health insurance marketplace, and the public healthcare programs that cover those who are without private health insurance.
So join us in The Basement for Tech Café. Go to the historic post office in downtown Reno, then head downstairs. Listen, learn, enter to win raffle prizes — and answer your pressing health insurance questions.
Health Reform Bulletin 116 | Year-End Wrap Up Dec. 29, 2015CBIZ, Inc.
The government is winding up 2015 and ringing in 2016 with a bang. The final HRB of 2015 will keep you abreast of the various changes that occurred at the end of the year.
Health Reform Bulletin 116 Year End Wrap Up 12-29-15Daniel Michels
The most recent CBIZ Health Reform Bulletin: Year-End Wrap Up (HRB 116). This issue includes specific information and guidance on:
1. Late breaking development, IRS delays new Affordable Care Act's (ACA) reporting and disclosure obligations!
2. On December 18, 2015 Consolidate Appropriations Act, 2016, and the Protecting Americans from Tax Hikes (PATH) Act of 2015 (H. R. 2029; now Public Law No. 114-113) were signed by the President, and amend several provisions of the Affordable Care Act.
3. The IRS Issued guidance relating to ACA implementation
4. Year-End Reminders
The long-term costs of major health care programs: fiscal implications and pr...OECD Governance
This presentation was made by Jessica Banthin, United States, at the 4th meeting of the Joint DELSA/GOV-SBO Network on Fiscal Sustainability of Health Systems, held in Paris on 16-17 February 2015.
delsa-gov-sbo-health-february-2015
This presentation explains the process followed by CBO and the staff of the Joint Committee on Taxation (JCT) when estimating the costs of legislative proposals affecting health insurance coverage. An example is the agencies’ estimate of how repealing the individual mandate to have health insurance would affect federal deficits.
Presentation by Sarah Masi, an analyst in CBO’s Budget Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
Presentation by Philip Ellis, CBO’s Deputy Assistant Director for Health, Retirement, and Long-Term Analysis, to staff of the U.S. Department of Commerce.
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Spending on federal health care programs is growing rapidly, driven by rising enrollment and rising health care spending per enrollee. This presentation describes CBO’s analyses related to health care, explains how the agency uses its health insurance simulation model, and provides examples of how CBO documents its work.
Presentation by Robert Sunshine, Senior Advisor in CBO’s Office of the Director, at the 10th Annual Meeting of the OECD Network of Parliamentary Budget Officials and Independent Fiscal Institutions.
Presentation by Ben Page, CBO's Fiscal Policy Studies Unit Chief, at the National Tax Association 108th Annual Conference on Taxation.
In May, the Congress adopted a concurrent resolution on the budget for fiscal year 2016. That resolution requires CBO, to the greatest extent practicable, to incorporate macroeconomic effects into its 10-year cost estimates for major legislation that Congressional committees approve. Such estimates must also include, when practicable, a qualitative assessment of the budgetary effects for the following 20 years. Incorporating such macroeconomic feedback into cost estimates is often called dynamic scoring. This presentation describes how CBO will prepare such estimates.
Presentation by Jared Jageler, David Adler, Noelia Duchovny, and Evan Herrnstadt, analysts in CBO’s Microeconomic Studies and Health Analysis Divisions, at the Association of Environmental and Resource Economists Summer Conference.
Presentation by Mark Hadley, CBO's Chief Operating Officer and General Counsel, at the 2nd NABO-OECD Annual Conference of Asian Parliamentary Budget Officials.
Presentation by Daria Pelech, an analyst in CBO’s Health Analysis Division, at the Center for Health Insurance Reform McCourt School of Public Policy, Georgetown University.
This slide deck highlights CBO’s key findings about the outlook for the economy as described in its new report, The Budget and Economic Outlook: 2024 to 2034.
Presentation by CBO analysts Rebecca Heller, Shannon Mok, and James Pearce, and Census Bureau research economist Jonathan Rothbaum at the American Economic Association Annual Meeting, Committee on Economic Statistics.
Presentation by Eric J. Labs, an analyst in CBO’s National Security Division, at the Bank of America 2024 Defense Outlook and Commercial Aerospace Forum.
Presentation by Elizabeth Ash, William Carrington, Rebecca Heller, and Grace Hwang of CBO’s Labor, Income Security, and Long-Term Analysis and Health Analysis divisions to the Children’s Health Group, American Academy of Pediatrics.
Presentation by Molly Dahl, Chief of CBO’s Long-Term Analysis Unit, at a meeting of the National Conference of State Legislatures’ Budget Working Group.
In the President’s 2024 budget request, total military compensation is $551 billion, including veterans' benefits. That amount represents an increase of 134 percent since 1999 after removing the effects of inflation.
ZGB - The Role of Generative AI in Government transformation.pdfSaeed Al Dhaheri
This keynote was presented during the the 7th edition of the UAE Hackathon 2024. It highlights the role of AI and Generative AI in addressing government transformation to achieve zero government bureaucracy
Jennifer Schaus and Associates hosts a complimentary webinar series on The FAR in 2024. Join the webinars on Wednesdays and Fridays at noon, eastern.
Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
A process server is a authorized person for delivering legal documents, such as summons, complaints, subpoenas, and other court papers, to peoples involved in legal proceedings.
Jennifer Schaus and Associates hosts a complimentary webinar series on The FAR in 2024. Join the webinars on Wednesdays and Fridays at noon, eastern.
Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
This session provides a comprehensive overview of the latest updates to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (commonly known as the Uniform Guidance) outlined in the 2 CFR 200.
With a focus on the 2024 revisions issued by the Office of Management and Budget (OMB), participants will gain insight into the key changes affecting federal grant recipients. The session will delve into critical regulatory updates, providing attendees with the knowledge and tools necessary to navigate and comply with the evolving landscape of federal grant management.
Learning Objectives:
- Understand the rationale behind the 2024 updates to the Uniform Guidance outlined in 2 CFR 200, and their implications for federal grant recipients.
- Identify the key changes and revisions introduced by the Office of Management and Budget (OMB) in the 2024 edition of 2 CFR 200.
- Gain proficiency in applying the updated regulations to ensure compliance with federal grant requirements and avoid potential audit findings.
- Develop strategies for effectively implementing the new guidelines within the grant management processes of their respective organizations, fostering efficiency and accountability in federal grant administration.
What is the point of small housing associations.pptxPaul Smith
Given the small scale of housing associations and their relative high cost per home what is the point of them and how do we justify their continued existance
What is the point of small housing associations.pptx
Coverage Effects of Limiting the Tax Exclusion for Employment-Based Health Insurance
1. Congressional Budget Office
Coverage Effects of Limiting the
Tax Exclusion for Employment-Based
Health Insurance
Presentation at the Fifth Biennial Conference
of the American Society of Health Economists
June 23, 2014
Allison Percy,
Health, Retirement, and Long-Term Analysis Division
2. 1C O N G R E S S I O N A L B U D G E T O F F I C E
About This Presentation
The estimates in this presentation are preliminary and are being
circulated to stimulate discussion and critical comment
as developmental work for analysis of interest to Members of
the Congress.
The underlying analysis was conducted by Allison Percy,
Alexandra Minicozzi, and Jessica Banthin of the Congressional
Budget Office and Pamela Moomau of the staff of the Joint
Committee on Taxation.
That research embodies work undertaken for the staff of the
Joint Committee on Taxation, but as members of both parties
and both houses of Congress compose the Joint Committee on
Taxation, this work should not be construed to represent the
position of any member of the Committee.
3. 2C O N G R E S S I O N A L B U D G E T O F F I C E
About This Presentation (Continued)
The results in this presentation expand on those published
in Congressional Budget Office, Options for Reducing the Deficit:
2014 to 2023 (November 2013), www.cbo.gov/
budget-options/2013/44903, using the most recent CBO baseline.
For health insurance coverage estimates under that baseline, see
Congressional Budget Office, Updated Estimates of the Effects of
the Coverage Provisions of the Affordable Care Act (April 2014),
www.cbo.gov/publication/45231.
For more information about CBO’s HISIM microsimulation model,
see Jessica Banthin, Deputy Assistant Director, Congressional
Budget Office, “Microsimulation of Demand for Health
Insurance: A Method Based on Elasticities” (presentation to the
AcademyHealth Annual Research Meetings, San Diego, CA, June
9, 2014), http://www.cbo.gov/publication/45427.
4. 3C O N G R E S S I O N A L B U D G E T O F F I C E
Tax Exclusion for Employment-Based Health Insurance
■ Premiums paid by employers for health insurance are excluded
from employees’ taxable wage income and are thus exempt
from federal income and payroll taxes.
■ Most employees can also pay their share of premiums with
pretax earnings.
■ Self-employed people can deduct their health insurance
premiums from their federal income taxes (but not from their
self-employment payroll taxes).
5. 4C O N G R E S S I O N A L B U D G E T O F F I C E
Effects of the Tax Exclusion
■ Reduces the cost of health insurance for employees whose
employers offer such coverage
■ Reduces the cost of employment-based coverage relative to
nongroup insurance (holding benefits constant)
■ Encourages workers to take up coverage
■ Encourages employment-based coverage, which pools risks
and spreads out fixed costs
6. 5C O N G R E S S I O N A L B U D G E T O F F I C E
Effects of the Tax Exclusion (Continued)
■ Encourages choice of more generous insurance plans
■ Spurs health care cost growth
■ Reduces tax revenues
■ Subsidizes high-income groups more than low-income groups
7. 6C O N G R E S S I O N A L B U D G E T O F F I C E
How Big is the Tax Subsidy and How Does It
Vary by Income?
■ Income tax
– Marginal federal income tax rates rise with income
■ Payroll tax
– Includes both employers’ and employees’ shares of Social Security
and Medicare taxes
– The amount of income subject to Social Security taxes is capped, so
rates fall with income
■ Average marginal tax rates for federal income and payroll
taxes combined range from 8% for incomes less than $10,000
to 45% for incomes greater than $1 million per year
■ Most states also impose income taxes that exclude the
value of employment-based health insurance premiums
Source: Joint Committee on Taxation.
8. 7C O N G R E S S I O N A L B U D G E T O F F I C E
Coverage Effects of Limiting the Tax Exclusion for
Employment-Based Health Insurance, 2008
Pre-Policy
Levels
Completely
Eliminate Income
and Payroll Tax
Exclusion
Eliminate
Income Tax
Exclusion
Only
Cap Tax Exclusion
for Income and
Payroll Tax at
Median Premium
Employment-
based coverage 154 -15 -10 -2
Nongroup /
public 37 +4 +2 n.a.
Uninsured 49 +11 +8 +1
Source: Jonathan Gruber.
Note: n.a. = not available.
(Millions of nonelderly people covered)
9. 8C O N G R E S S I O N A L B U D G E T O F F I C E
Why Would Effect Be Different Today?
■ Limited alternatives to employment-based coverage
before 2014
– Public coverage
• Many low income adults did not qualify for Medicaid
• Few other public insurance options were available for most people
– Nongroup coverage
• Very few subsidies or tax preferences available unless self-employed
• Difficult to access or afford for those with pre-existing conditions
■ The Affordable Care Act (ACA)
– New coverage options
– New rules governing nongroup and employment-based coverage
10. 9C O N G R E S S I O N A L B U D G E T O F F I C E
Coverage Provisions of the Affordable Care Act
■ Many individuals and families between 100 and 400 percent of
the federal poverty line are able to purchase subsidized
insurance through exchanges (or marketplaces).
■ Insurers may not deny coverage to people on the basis of their
health status or charge enrollees in poor health higher
insurance premiums.
■ States are permitted to significantly expand eligibility for
Medicaid but may decline to do so.
■ Most legal residents of the United States must either obtain
health insurance or pay a penalty.
11. 10C O N G R E S S I O N A L B U D G E T O F F I C E
Coverage Provisions of the Affordable Care Act (Continued)
■ Most employers with more than 50 full-time employees that
decline to offer minimum health insurance coverage to their
employees will be assessed penalties.
■ A federal excise tax will be imposed on some health insurance
plans with high premiums starting in 2018.
■ Health insurance rules are changed in other ways
12. 11C O N G R E S S I O N A L B U D G E T O F F I C E
Projected Health Insurance Coverage in the U.S., 2024
(Millions of nonelderly people)
13. 12C O N G R E S S I O N A L B U D G E T O F F I C E
How CBO and JCT Model Health Insurance Coverage
■ CBO and JCT estimate health insurance coverage effects of
proposals, such as the ACA and proposed changes to the tax
exclusion, using a microsimulation model (HISIM) and other
models.
■ HISIM is based on individual and family information from the
Survey of Income and Program Participation (SIPP).
■ HISIM calculates changes in the price of health insurance and
uses a price elasticity of demand for health insurance to
measure change in take-up of different types of coverage.
14. 13C O N G R E S S I O N A L B U D G E T O F F I C E
How CBO and JCT Model Health Insurance Coverage
(Continued)
■ Coveraget+1= f(Coveraget, %Δ Price * Elasticity, X)
– X = health status, income, family status, etc.
– Equations for each possible status change, including addition or
subtraction of new options
– Availability of options depends on eligibility (for public programs) and
offer status (for employment-based plans)
15. 14C O N G R E S S I O N A L B U D G E T O F F I C E
How CBO and JCT Model Firms’ Offers of
Employment-Based Coverage
■ Δpr(offeri) = εf * %Δpi
– f is the size of firm i
– εf is the elasticity of the change in probability of a firm offering, Δpr,
with respect to a percent change in price, %Δpi
■ Separable and additive probabilities of changing offer status
based on various after-tax prices
– Changes in the price of employment-based coverage
– Changes in the price of alternative sources of coverage (nongroup,
Medicaid, exchange plans) available to firm’s employees
■ Incorporates any available subsidies and the perceived
substitutability of alternative coverage types
16. 15C O N G R E S S I O N A L B U D G E T O F F I C E
Illustrative Policies to Limit the Tax Exclusion
■ Totally eliminate the tax exclusion for federal income tax and
payroll tax purposes
■ Eliminate the tax exclusion for federal income tax but not for
payroll tax purposes
■ Cap income and payroll tax exclusions at the median premium
for employment-based plans
17. 16C O N G R E S S I O N A L B U D G E T O F F I C E
Comparing Estimates of the Coverage Effects of
Eliminating the Income and Payroll Tax Exclusion
Gruber CBO/JCT CBO/JCT
Pre-ACA Pre-ACA Under the ACA
Employment-based
coverage -6% -9% -26%
Nongroup / public +2% +4% +21%
Uninsured +5% +5% +5%
Source: Jonathan Gruber, Congressional Budget Office, and staff of the Joint Committee on Taxation.
(Change in percentage of nonelderly population covered)
18. 17C O N G R E S S I O N A L B U D G E T O F F I C E
Three Approaches to Limiting the Tax Exclusion:
Change in Health Insurance Coverage Under the ACA in 2017
(Millions of nonelderly people)
17 17 17 17
5 4 4 5
155
83
107
150
25
79
59
28
45
49 48
46
30
42 40
31
0
50
100
150
200
250
300
Current Law --
Full Tax
Exclusion
Completely
Eliminate Tax
Exclusion
Eliminate Income
Tax Exclusion
Only
Cap Income and
Payroll Tax
Exclusions at
Median Premium
Uninsured
Medicaid and CHIP
Exchanges
Employment-Based
Nongroup
Other
19. 18C O N G R E S S I O N A L B U D G E T O F F I C E
Three Approaches to Limiting the Tax Exclusion:
Change in Health Insurance Coverage Under the ACA in 2017
Current Law
Levels with
Full Tax
Exclusion
Completely
Eliminate Tax
Exclusion
Eliminate
Income Tax
Exclusion
Only
Cap Income
and Payroll
Tax Exclusions
at Median
Premium
Exchanges 25 +54 +34 +3
Medicaid and CHIP 45 +4 +3 0
Employment-based
coverage
155 -73 -49 -5
Nongroup 5 -1 -1 *
Other 17 * * *
Uninsured 30 +12 +10 +1
Source: Congressional Budget Office and staff of the Joint Committee on Taxation.
Note: * = between -0.5 million and +0.5 million
(Millions of nonelderly people covered)
20. 19C O N G R E S S I O N A L B U D G E T O F F I C E
Three Approaches to Limiting the Tax Exclusion:
Percentage of People Without Insurance in 2017, by Income Group
16%
18%
18%
16%
8%
13%
12%
8%
4%
11%
10%
5%
0%
5%
10%
15%
20%
25%
Full Tax Exclusion Completely Eliminate Tax
Exclusion
Eliminate Income Tax
Exclusion Only
Cap Tax Exclusion at
Median Premium
< 200% FPL 200-399% FPL 400+% FPL
21. 20C O N G R E S S I O N A L B U D G E T O F F I C E
Three Approaches to Limiting the Tax Exclusion: Percentage of
People with Employment-Based Coverage in 2017, by Income Group
27%
12%
16%
27%
70%
37%
49%
68%
86%
50%
62%
83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Full Tax Exclusion Completely Eliminate Tax
Exclusion
Eliminate Income Tax
Exclusion Only
Cap Tax Exclusion at
Median Premium
< 200% FPL 200-399% FPL 400+% FPL
22. 21C O N G R E S S I O N A L B U D G E T O F F I C E
Sources
Slide 5: Joint Committee on Taxation, Overview of the Federal Tax
System As In Effect for 2014 (March 28, 2014), http://go.usa.gov/9qNT.
Slide 6: Jonathan Gruber, “The Tax Exclusion for Employer-
Sponsored Health Insurance,” National Tax Journal (June 2011),
Tables 2 and 5; Jonathan Gruber, The Tax Exclusion for Employer-
Sponsored Health Insurance, Working Paper 15766 (National
Bureau of Economic Research February 2010), Table 4; and
Jonathan Gruber, personal communication (June 17, 2014).
Slide 10: Congressional Budget Office, Updated Estimates of the
Effects of the Insurance Coverage Provisions of the Affordable
Care Act, April 2014, www.cbo.gov/publication/45231.