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On March 23, 2010, President Barack Obama signed into law a sweeping reform of the U.S. health care system. The law, as signed, imposes a host of new requirements on private insurance companies. It expands existing government insurance programs, creates new institutions to oversee insurance markets, offers new subsidies to the uninsured, and requires citizens to have coverage - all in order to expand access to health care to 32 million uninsured U.S. citizens and legal residents.
Of course, it remains to be implemented. Congress can still delay. Republicans who opposed the bill may refuse funding for individual provisions, and if they win a majority in the 2010 Congressional midterm elections, they may be able to repeal the bill entirely.
The key date is really 2014, when many of the provisions of the legislation will begin. A new Republican president in 2012 could have a substantial impact on implementation.
As it stands right now, three questions remain. What will happen? When will it happen? Who is responsible?
First, the Department of Health and Human Services (HHS) will take the lead in writing regulations and guidelines for the reform. The Department of Labor (DOL) and the Internal Revenue Service (IRS), which regulate employee benefits plans, will assist. HHS has established a new Office of Consumer Information and Insurance Oversight to head up this effort.
Next, the National Association of Insurance Commissioners (NAIC) is an organization that speaks for the state insurance commissioners and drafts model laws and regulations for the states. The law asks the NAIC to advise HHS with respect to many of its responsibilities such as defining minimum loss ratios. Most of the NAIC's work will be done in 2010, although some may take place later.
Finally, states have a huge role. The legislation depends heavily on states, which traditionally regulate health insurance, to implement key provisions, and it gives them the flexibility and authority (as well as substantial funding) to do so.
Twenty-one states are suing in federal court to challenge the law. While these cases will probably be dismissed on jurisdictional grounds in 2010 or 2011, further litigation may take place once the law is implemented in 2014.
There is also a slight chance a federal court may strike down the individual insurance mandate provision after implementation. So far, though, the primary impact of the litigation has been to raise questions of the legitimacy of the reforms.
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 Department of Health and Human Services |
 Department of Labor |
 Internal Revenue Service |
 National Association of Insurance Commissioners |
 State Governments * |
 Food and Drug Administration |
| * States must follow the federal law or leave medicaid, but the law allows discretion over various program aspects, like denial of benefits. | ||||||
Parents' insurance plans required to cover adult children up to age 26. Lifetime limits on coverage eliminated and annual limits on coverage restricted. Insurers required to cover specific preventive services-e.g. mammograms and pap smears-without deductibles, copayments or coinsurance. Providers prohibited from terminating coverage of enrollees except for cases of fraud. Internal review procedures required to allow enrollees to appeal denied claims.
Reinsurance program created for early retirees. Web portal created to provide comparitive information to insurance consumers.
High-risk pool program established for uninsured persons with preexisting conditions. States have the option to operate; three-fifths have chosen to do so. Review procedures for insurance rates written.
Tax credit program created for small businesses to insure their employees.
Rebate of $250 provided to Medicare beneficiaries to fill the gap between ordinary coverage and catastrophic coverage of medication- the "doughnut hole."
Discretionary expansion of state Medicaid programs to cover childless adults.
Discretionary expansion (with partial federal funding) of state Medicaid programs to increase eligibility for family planning services.
Program created that will provide for approval of the sale of generic biologics, similar to the current program for the approval of generic drugs.
| Program created that will provide for approval of the sale of generic biologics, similar to the current program for the approval of generic drugs. |
Insurers required to provide rebates to enrollees if a specified percentage of premiums are not spent on medical claims or activities to improve quality of care.
Draft regulations for exchanges to market and regulate
health insurance in small markets.
see 1 in 2014
Establish a new national voluntary program for purchasing
community living assistance services and supports.
Draft the regulations in 2010-2011 to give states time to
implement reinsurance and risk adjustment programs.
see 4 in 2014
Regulation or legislation must be adopted in 2011-2012
to allow time for implementation of required minimum
health insurance laws and insurance penalties.
see 2 and 3 in 2014
Phased-in elimination of the "doughnut hole" begins, to be completed by 2020.
Cost sharing eliminated in Medicare for specific preventive services.
New quality and cost-control programs, such as providing "health homes" for Medicaid recipients with chronic illnesses and restraining Medicare payment increases for hospitals.
Additional payments to primary care physicians and surgeons who practice in areas with physician shortages.
Insurers required to disclose certain information--such as benefit and cost-sharing descriptions--using standard, easily readable formats.
HHS must determine by 2013 whether the states will
be ready to establish the insurance exchanges by
the 2014 deadline (and take over if they are not).
see 1 in 2014
New cost control and quality improvement programs implemented, such as shared-saving and value-based purchasing programs.
Insurers and group health plans required to provide coverage regardless of health status or preexisting conditions.
Providers prohibited from varying premiums based on health status.
Providers required to cover "essential benefits" small group and individual markets.
Eligibility waiting periods limited to 90 days. Deductibles limited in small group markets.
Providers required to meet additional conditions if they offer health plans through the exchanges.
1 Exchanges established to market and regulate health insurance. If a state fails to establish an exchange, HHS must do so.
Subsidies provided to help persons under 400 percent of the poverty level purchase health insurance. Costsharing obligations also limited. Subsidies only available for plans purchased through the exchanges.
2 Uninsured U.S. citizens and legal residents required to purchase minimum health insurance coverage or pay a tax if their income exceeds a certain level and they can afford health insurance.
3 Large employers pay a penalty if they do not provide adequate insurance for employees and employees receive public subsidies to purchase insurance.
4 New reinsurance and risk-adjustment programs created to shift funds from insurers with favorable risk pools to those with unfavorable risk pools.
Coverage expanded to all Americans with incomes up to 133 percent of the poverty level. The federal government covers 100 percent of the cost for the first three years, after which states' share of the cost grows to 10 percent by 2020.
