[307]

Percentage of Individuals in the United States without Health Insurance, 1963–2015 (Source: JAMA)[308]
The costs of these provisions are offset by taxes, fees, and cost-saving measures, such as new Medicare taxes for those in high-income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies;[309] there is also a tax penalty for those who do not obtain health insurance, unless they are exempt due to low income or other reasons.[310] In March 2010, the CBO estimated that the net effect of both laws will be a reduction in the federal deficit by $143 billion over the first decade.[311]
The law faced several legal challenges, primarily based on the argument that an individual mandate requiring Americans to buy health insurance was unconstitutional. On June 28, 2012, the Supreme Court ruled by a 5–4 vote in National Federation of Independent Business v. Sebelius that the mandate was constitutional under the U.S. Congress's taxing authority.