In a symposium focused on healthcare cost control, most of our authors have unsurprisingly highlighted and assessed Obamacare’s payment and delivery reforms—the supply-side efforts to decrease costs of medical treatment. But there is another party in healthcare decision-making who is equally or even more important: the patient. The question we will tackle here is whether the individual mandate and its accompanying patient-centered insurance reforms might decrease costs for patients in ways that ought to matter in assessing Obamacare’s cost control provisions.

The individual mandate’s cost control potential lies in its reduction or even elimination of patients’ decision costs. The mandate, together with its minimum coverage requirements and a handful of the statute’s substantive insurance reforms, combats demand-side inefficiencies that might arise from patients’ bounded rationality. Decisions about whether to buy commercial insurance, how much insurance to buy, whether to consume preventive care, and how much to pay for that care are all difficult decisions. In order to make optimal choices, patients need a lot of information that is costly to obtain and to evaluate.

Upon the death of a king or queen, the proclamation “the king is dead, long live the king” announces a new monarch’s accession to the throne, preserving the sovereign order. As the Patient Protection and Affordable Care Act (ACA) is implemented, it is tempting to proclaim the reign of a new system of health insurance. But, will it preserve the old order or initiate a new form of governance? As states and insurers grapple with new rules and regulations being issued from the Department of Health and Human Services, the Treasury Department and the Department of Labor, one might believe an entirely new health insurance system is being built. Yet, the ACA is designed to preserve existing forms of public and private health insurance, such as Medicare and private employer group health plans, which will continue to operate much as they have in the recent past. What has changed is the role that insurance will play and how that will shape the way we think about health policy.

There has been great debate about the potential labor market impact of the Affordable Care Act (“ACA” or “Obamacare”). Some have pointed to Massachusetts as the harbinger of what is to come nationally, while others have predicted massive dumping of employer-based insurance. An extension of this labor market debate was on full display during the summer of 2012. Critics seized on a McKinsey & Co. survey that found that Obamacare could result in thirty percent of companies dropping employer-sponsored insurance (ESI). Meanwhile, proponents of the ACA quickly and continually referred to the experience of companies in Massachusetts as a way to push back on this narrative.

Surprisingly, there is bipartisan agreement that Massachusetts’s own health reform efforts (“Romneycare”) does in fact serve as an accurate model for what to expect under the federal law: this has complicated a lucid discussion of the ACA’s potential labor market impact.

In Obamacare’s Impact on Labor Markets: Limits on the Predictive Value of Romneycare, Josh Archambault makes a number of arguments about the ultimate impact of the Affordable Care Act (ACA). A central point is that the overall impact on the US labor market and economy will be worse than the Congressional Budget Office (CBO) projected—to some extent, because the CBO used the experience in Massachusetts as one piece of evidence in guiding its estimates. A recent report by the CBO on potential effects of the ACA on employment has added additional fuel to the debate. In particular, Archambault argues that more people will leave employer-sponsored insurance (ESI), and that the ACA will cost more than the CBO projected.

Archambault makes many good points. The ACA does add new taxes, such as an additional 1% Medicare tax on families earning over $250,000, a 2.3% tax on medical devices, and additional taxes on some health insurers and tanning salons. Altogether, these taxes were expected to raise roughly $400 billion between 2010 and 2019.

As enacted, the Affordable Care Act (ACA) directed states to provide Medicaid coverage to most nonelderly adults with incomes up to 138% of the Federal Poverty Level (the “Medicaid expansion group”) beginning in 2014. The Medicaid expansion provision of the ACA is an integral component of fulfilling the ACA’s primary objective to achieve near-universal health insurance coverage rates across the United States.

Title XIX of the Social Security Act (Title XIX) is Medicaid’s enabling statute. Medicaid is a medical assistance program for certain low-income individuals, jointly funded and administered by federal and state governments. Certain features of the Medicaid program provide a framework within which the ACA and subsequent Supreme Court decision National Federation of Independent Business (NFIB) v. Sebelius can be understood.

As of January 2014, 26 states had chosen to expand Medicaid under the Affordable Care Act (ACA) to cover individuals with incomes up to 138% of the federal poverty level. In these states, Medicaid agencies are facing one of the largest implementation challenges in the program’s history. We undertook a survey of high-ranking Medicaid officials in these states to assess their priorities, expectations, and programmatic decisions related to the coming expansion.

The Medicaid expansion poses major challenges in the domains of enrollment, management of health care costs, and providing adequate access to services for beneficiaries. Previous research has documented that millions of individuals eligible for Medicaid are currently not enrolled and remain uninsured, suggesting that state outreach strategies may underpin the success or failure of the ACA’s coverage expansion.

This Note focuses on the medical loss ratio provision (“MLR Provision”) of the Patient Protection and Affordable Care Act (ACA). The MLR Provision states that health insurance companies must spend at least a certain percentage of their premium revenue on “activities that improve healthcare quality” (in other words, meet a minimum threshold medical loss ratio) and comply with reporting requirements determined by the Secretary of the United States Department of Health and Human Services (HHS). Because states have historically had authority over the regulation of health insurance, there is an outstanding question as to whether or not the MLR Provision has legal authority to preempt conflicting state MLR regulations.

Part II of this Note outlines the major requirements in the MLR Provision and discusses the history of MLR regulation in the United States. Part III discusses the likelihood that the courts will soon resolve the question of preemption regarding the MLR Provision.

Regenerative Sciences, LLC, a Colorado company run by physicians, created the Regenexx-C (Cultured) (“Regenexx-C”) procedure to treat bone pain. The procedure involves harvesting a patient’s own mesenchymal stem cells (MSCs), expanding the cells ex vivo, and then injecting the resulting cellular product into the site of injury, usually an injured joint. The MSCs then repair the damaged tissue. On July 23, 2012, the United States Food and Drug Administration (FDA) won a permanent injunction against Regenerative Sciences in district court, preventing the company from offering the procedure because the MSCs were adulterated and misbranded “drugs” under the Federal Food, Drug, and Cosmetic Act (FDCA). The Court of Appeals for the D.C. Circuit recently upheld the ruling.