In the United States, the debate regarding healthcare reform includes questions of a right to health care, access, fairness, sustainability, quality and amounts spent by government. The mixed public-private health care system in the United States is the most expensive in the world, with health care costing more per person than in any other nation, and a greater portion of gross domestic product (GDP) is spent on it than in any other United Nations member state except for East Timor (Timor-Leste).[1] A study of international health care spending levels in the year 2000, published in the health policy journal Health Affairs, found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.[2] In spite of the amount spent on health care in the U.S., according to a 2008 Commonwealth Fund report, the United States ranks last in the quality of health care among developed countries.[3] The World Health Organization (WHO), in 2000, ranked the US health care system 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).[4][5] International comparisons that could lead to conclusions about the quality of the health care received by Americans are subject to debate. The US pays twice as much yet lags other wealthy nations in such measures as infant mortality and life expectancy, which are among the most widely collected, hence easily compared, international statistics. Many people are underinsured, for example, in Colorado "of those with insurance for a full year, 36.3% were underinsured."[6][7] About 10.7 million insured Americans spend more than a quarter of their annual paychecks on health care because of the high deductible polices.[8] The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed March 30), the Act is a product of the health care reform efforts of the Democratic 111th Congress and the Obama administration. The law includes health-related provisions to take effect over the next four years, including expanding Medicaid eligibility for people making up to 133% of the federal poverty level (FPL),[9] subsidizing insurance premiums for people making up to 400% of the FPL ($88,000 for family of 4 in 2010) so their maximum "out-of-pocket" payment for annual premiums will be from 2% to 9.5% of income,[10][11] providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing health insurance exchanges, prohibiting insurers from establishing annual coverage caps, and support for medical research. According to White House and Congressional Budget Office figures, the maximum share of income that enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative to the federal poverty level, as follows:[10][12] for families with income 133–150% of FPL will be 3-4% of income, for families with income of 150–200% of FPL will be 4-6.3% of income, for families with income