Healthcare construction changes becuase of affordable care act

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The site is secure. NCBI Bookshelf. This list is the rapporteurs' summary of the main points made by individual speakers and participants, and does not reflect any consensus among workshop participants. Key features of the Affordable Care Act ACA are access to health care through expanded coverage, improved quality and efficiency and lower health care costs, and consumer protections. Incremental reforms have been made to the ACA since it was passed in For example, expanded coverage will not be universal coverage, because some states are electing to not expand their Medicaid programs, and the change in care management will not happen overnight, as all of the speakers point out in this chapter.

Comprehensive changes that take effect in were summarized by Jack Ebeler, principal, Health Policy Alternatives see Box Understanding the reforms and details of the law can help to clarify how preparedness programs should adapt to the changing health care delivery landscape.

The mechanism for organizing the individual and small group insurance markets and administering subsidies. The health insurance marketplace includes state-based exchanges and more Additionally, although in effect prior to , one ruling that is notable for preparedness efforts previously mentioned by Lurie is the New Requirements for Charitable c 3 Hospitals.

It imposes new requirements on c 3 organizations that operate one or more hospital facilities hospital organizations. One of the requirements is to conduct a community health needs assessment CHNA and adopt an implementation strategy for addressing the prioritized health needs at least once every 3 years.

The ACA also added section , which imposes an excise tax for failure to meet the CHNA requirements, and added reporting requirements under section b related to sections r and Lisa Tofil, partner at Holland and Knight, explained that expansion of health care coverage under the ACA is achieved by expansion of Medicaid eligibility up to percent of the federal poverty level 6 :.

In , in response to a constitutional challenge to the ACA, the Supreme Court upheld the individual mandate, but the Medicaid expansion became optional for states. As a result, there may be significant gaps in coverage in states that decide to not expand their Medicaid programs, Tofil said. People between and percent of the federal poverty level in any state can get the sliding-scale subsidy when selecting coverage in the federal health exchange, Ebeler explained.

But those below percent of the poverty level and above current Medicaid coverage limits will have no source of subsidy in the states that are not expanding their programs. As of fall , about half of the states are not moving forward with Medicaid expansion Kaiser Family Foundation, , which could leave as many as 6 million uninsured, nonelderly adults without access to coverage.

Ebeler said it is important to consider implementation of the ACA over the longer term, pointing out that when Medicaid went into effect in , only 26 states participated in the first year, but 4 years later in , nearly all states were participating. He cautioned that even with the ACA, there will still not be universal coverage. Current projections show that overall, including those with lowest income living in non-Medicaid expansion states, undocumented residents, and those unwilling to purchase their own insurance, 30 million Americans will still lack coverage by Nardin et al.

As summarized by Ebeler, there are two key fundamental changes in financing and delivery underlying system reform. First, is the shift in measurement and payment, moving from discrete fee-for-service transactions payment for each task or service that is done at each moment to payment for clinically and economically relevant episodes for patients and providers, referred to as bundled payments.

Accountability for care may be spread across provider types and over a period of time, which incentivizes those providers to work together and integrate services and provides some degree of risk transfer. Second, there is a change in care-management capacity to favor providers over insurers in driving health care decisions.

Groups of providers e. Ebeler referred to work of the Commonwealth Fund, which suggests that it is easier to implement combinations of payment, accountability, and risk if delivery is more collaborative and integrated Davis and Schoenbaum, Tofil highlighted other key changes to payments for providers under the ACA. Partially through Section , they focus on value-based payments to incentivize quality and safety as well as to lower use and increase efficiency.

There are Medicare and Medicaid penalties for health care—acquired conditions not limited to hospital acquired , penalties for excessive preventable Medicare readmissions, as well as a focus on value-based purchasing i. ACOs, which will primarily still be fee-for-service, will focus on prevention and wellness to minimize hospitalizations, readmissions, and unnecessary care use.

There are also market-driven innovations in payment through various methods. Increased transparency has led to downward price pressure, tougher negotiations by employers with insurers, and a greater need to demonstrate value. One area of payment reform that was of particular concern to some participants who spoke was cuts to the disproportionate share hospital DSH payments for both Medicare and Medicaid.

This means that states that do not expand Medicaid will provide about the same level of uncompensated care to uninsured individuals but will now receive less federal funding for that care discussed further in Chapter 3. Many participants noted this has dire implications for safety net hospitals, especially in a disaster.

Cap total payments, including bonuses, at current payment levels. Reduce annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice and other Medicare providers, and adjust for productivity.

Effective January 1, Establish an Independent Payment Advisory Board comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate. If so, beginning January 15, , the Board will submit recommendations to achieve reductions in Medicare spending.

Beginning January , the target is modified such that the board submits recommendations if Medicare per capita spending exceeds GDP per capita plus one percent. The Board will submit proposals to the President and Congress for immediate consideration. The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing including Parts A and B premiums , or would result in a change in the beneficiary premium percentage or low-income subsidies under Part D.

Hospitals and hospices through and clinical labs for one year will not be subject to cost reductions proposed by the Board.

The Board must also submit recommendations every other year to slow the growth in national health expenditures while preserving quality of care by January 1, Effective upon enactment Allow providers organized as accountable care organizations ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians, define processes to promote evidence-based medicine, report on quality and costs, and coordinate care.

Shared savings program established January 1, Create an Innovation Center within the Centers for Medicare and Medicaid Services to test, evaluate, and expand in Medicare, Medicaid, and CHIP different payment structures and methodologies to reduce program expenditures while maintaining or improving quality of care.

Payment reform models that improve quality and reduce the rate of cost growth could be expanded throughout the Medicare, Medicaid, and CHIP programs. Effective January 1, Reduce Medicare payments that would otherwise be made to hospitals by specified percentages to account for excess preventable hospital readmissions. Effective fiscal year Medicaid Increase the Medicaid drug rebate percentage for brand name drugs to Effective January 1, Extend the drug rebate to Medicaid managed care plans.

Require the Secretary to develop a methodology to distribute the DSH reductions in a manner that imposes the largest reduction in DSH allotments for states with the lowest percentage of uninsured or those that do not target DSH payments, imposes smaller reductions for low-DSH states, and accounts for DSH allotments used for waivers.

Effective October 1, Prohibit federal payments to states for Medicaid services related to health care acquired conditions.

Effective July 1, Prescription drugs Authorize the Food and Drug Administration to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.

Effective upon enactment Waste, fraud, and abuse Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight periods for new providers and suppliers, including a day period of enhanced oversight for initial claims of DME suppliers, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs.

Develop a database to capture and share data across federal and state programs, increase penalties for submitting false claims, strengthen standards for community mental health centers and increase funding for anti-fraud activities. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels. Findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage.

Effective upon enactment Medical malpractice Award five-year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigations. Preference will be given to states that have developed alternatives in consultation with relevant stakeholders and that have proposals that are likely to enhance patient safety by reducing medical errors and adverse events and are likely to improve access to liability insurance.

Funding appropriated for five years beginning in fiscal year Medicare Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge.

If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program. Establish pilot program by January 1, ; expand program, if appropriate, by January 1, Create the Independence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction.

Effective January 1, Establish a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond Effective October 1, Develop plans to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers.

Reports to Congress due January 1, Dual eligibles Improve care coordination for dual eligibles by creating a new office within the Centers for Medicare and Medicaid services, the Federal Coordinated Health Care Office, to more effectively integrate Medicare and Medicaid benefits and improve coordination between the federal government and states in order to improve access to and quality of care and services for dual eligibles.

Effective March 1, Medicaid Create a new Medicaid state plan option to permit Medicaid enrollees with at least two chronic conditions, one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a health home.

Effective January 1, Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations effective January 1, through December 31, ; to make global capitated payments to safety net hospital systems effective fiscal years through ; to allow pediatric medical providers organized as accountable care organizations to share in cost-savings effective January 1, through December 31, ; and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition effective October 1, through December 31, Effective for five years beginning January 1, National quality strategy Develop a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health.

Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs. National strategy due to Congress by January 1, Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations.

Funds appropriated for five years beginning in FY Financial disclosure Require disclosure of financial relationships between health entities, including physicians, hospitals, pharmacists, other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies. Report due to Congress April 1, Disparities Require enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations.

Also require collection of access and treatment data for people with disabilities. Require the Secretary to analyze the data to monitor trends in disparities. Strategy due one year following enactment Create a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs. Initial appropriation in fiscal year Create task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.

Effective upon enactment Establish a Prevention and Public Health Fund for prevention, wellness, and public health activities including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs.

Effective fiscal year Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. Funds appropriated for five years beginning in FY Coverage of preventive services Eliminate cost-sharing for Medicare covered preventive services that are recommended rated A or B by the U. Preventive Services Task Force and waive the Medicare deductible for colorectal cancer screening tests.

Authorize the Secretary to modify or eliminate Medicare coverage of preventive services, based on recommendations of the U. Preventive Services Task Force. Effective January 1, Provide states that offer Medicaid coverage of and remove cost-sharing for preventive services recommended rated A or B by the U. Preventive Services Task Force and recommended immunizations with a one percentage point increase in the federal medical assistance percentage FMAP for these services.

Effective January 1, Authorize Medicare coverage of personalized prevention plan services, including a comprehensive health risk assessment, annually. Require the Secretary to publish guidelines for the health risk assessment no later than March 23, , and a health risk assessment model by no later than September 29, Effective January 1, Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs.

Effective January 1, or when program criteria is developed, whichever is first Require Medicaid coverage for tobacco cessation services for pregnant women. Effective October 1, Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U. Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women.

Effective six months following enactment Wellness programs Provide grants for up to five years to small employers that establish wellness programs. Funds appropriated for five years beginning in fiscal year Provide technical assistance and other resources to evaluate employer-based wellness programs. Conduct a national worksite health policies and programs survey to assess employer-based health policies and programs.

Employers must offer an alternative standard for individuals for whom it is unreasonably difficult or inadvisable to meet the standard. Effective January 1, Establish state pilot programs by July to permit participating states to apply similar rewards for participating in wellness programs in the individual market and expand demonstrations in if effective.

Require a report on the effectiveness and impact of wellness programs. Report due three years following enactment Nutritional information Require chain restaurants and food sold from vending machines to disclose the nutritional content of each item. The program is financed through voluntary payroll deductions: all working adults will be automatically enrolled in the program, unless they choose to opt-out. Effective October 1, Establish the Community First Choice Option in Medicaid to provide community-based attendant supports and services to individuals with disabilities who require an institutional level of care.

Provide states with an enhanced federal matching rate of an additional six percentage points for reimbursable expenses in the program. Effective October 1, Create the State Balancing Incentive Program to provide enhanced federal matching payments to eligible states to increase the proportion of non-institutionally-based long-term care services.

Effective October 1, through September 30, Skilled nursing facility requirements Require skilled nursing facilities under Medicare and nursing facilities under Medicaid to disclose information regarding ownership, accountability requirements, and expenditures. Publish standardized information on nursing facilities to a website so Medicare enrollees can compare the facilities. Require employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers.

Impose new regulations on health plans in the Exchanges and in the individual and small group markets. Beginning after , the penalty will be increased annually by the cost-of-living adjustment. Other requirements Require employers with more than employees to automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of coverage. All newly eligible adults will be guaranteed a benchmark benefit package that meets the essential health benefits available through the Exchanges.

The Supreme Court ruling on the constitutionality of the ACA upheld the Medicaid expansion, but limited the ability of HHS to enforce it, thereby making the decision to expand Medicaid optional for states. States have the option to expand Medicaid eligibility to childless adults beginning on April 1, , but will receive their regular FMAP until CHIP benefit package and cost-sharing rules will continue as under current law.

Provide states with the option to provide CHIP coverage to children of state employees who are eligible for health benefits if certain conditions are met. CHIP-eligible children who are unable to enroll in the program due to enrollment caps will be eligible for tax credits in the state Exchanges.

Legal immigrants who are barred from enrolling in Medicaid during their first five years in the U. Trending: ACA's Future. Require most U. Require U. Require employers with more than employees to automatically enroll employees into health insurance plans offered by the employer. Limit availability of premium credits and cost-sharing subsidies through the Exchanges to U. Beginning in , further adjust the premium contributions to reflect the excess of premium growth over CPI if aggregate premiums and cost sharing subsidies exceed.

Provisions related to the premium and cost-sharing subsidies are effective January 1, Provide cost-sharing subsidies to eligible individuals and families. Require verification of both income and citizenship status in determining eligibility for the federal premium credits.

Ensure that federal premium or cost-sharing subsidies are not used to purchase coverage for abortion if coverage extends beyond saving the life of the woman or cases of rape or incest Hyde amendment. If an individual who receives federal assistance purchases coverage in a plan that chooses to cover abortion services beyond those for which federal funds are permitted, those federal subsidy funds for premiums or cost-sharing must not be used for the purchase of the abortion coverage and must be segregated from private premium payments or state funds.

The credit phases-out as firm size and average wage increases. The credit will be available for two years. Create a temporary reinsurance program for employers providing health insurance coverage to retirees over age 55 who are not eligible for Medicare. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan.

Effective 90 days following enactment through January 1, Effective January 1, Increase the threshold for the itemized deduction for unreimbursed medical expenses from 7. The threshold amounts may be adjusted upwards if health care costs rise more than expected prior to implementation of the tax in The threshold amounts will be increased for firms that may have higher health care costs because of the age or gender of their workers. The aggregate value of the health insurance plan includes reimbursements under a flexible spending account for medical expenses health FSA or health reimbursement arrangement HRA , employer contributions to a health savings account HSA , and coverage for supplementary health insurance coverage, excluding dental and vision coverage.

Effective January 1, Eliminate the tax deduction for employers who receive Medicare Part D retiree drug subsidy payments. Effective January 1, Impose an excise tax of 2. Effective July 1, Exclude unprocessed fuels from the definition of cellulosic biofuel for purposes of applying the cellulosic biofuel producer credit.

Effective January 1, Clarify application of the economic substance doctrine and increase penalties for underpayments attributable to a transaction lacking economic substance. Effective upon enactment. Create state-based American Health Benefit Exchanges and Small Business Health Options Program SHOP Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to employees can purchase qualified coverage.

Permit states to allow businesses with more than employees to purchase coverage in the SHOP Exchange beginning in States may form regional Exchanges or allow more than one Exchange to operate in a state as long as each Exchange serves a distinct geographic area.

Funding available to states to establish Exchanges within one year of enactment and until January 1, Restrict access to coverage through the Exchanges to U.

Require the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity and at least one plan must not provide coverage for abortions beyond those permitted by federal law.

Each multi-state plan must be licensed in each state and must meet the qualifications of a qualified health plan. If a state has lower age rating requirements than , the state may require multi-state plans to meet the more protective age rating rules. These multi-state plans will be offered separately from the Federal Employees Health Benefit Program and will have a separate risk pool. Create the Consumer Operated and Oriented Plan CO-OP program to foster the creation of non-profit, member-run health insurance companies in all 50 states and District of Columbia to offer qualified health plans.

To be eligible to receive funds, an organization must not be an existing health insurer or sponsored by a state or local government, substantially all of its activities must consist of the issuance of qualified health benefit plans in each state in which it is licensed, governance of the organization must be subject to a majority vote of its members, must operate with a strong consumer focus, and any profits must be used to lower premiums, improve benefits, or improve the quality of health care delivered to its members.

This plan is only available in the individual market.

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Cover her, but not her family. Once today's proposed rule is finalized, starting next year, working families in America will get the help they need to afford full family coverage. For more on the impact this could have and who it could help, I'm joined by Margot Sanger-Katz.

She covers health care for The New York Times. So, the Affordable Care Act was designed to try to make insurance affordable for almost all Americans and had a bunch of different programs. One is, it said, if you work, your employer should make insurance available to you at a price that you can afford. And then there's another program, the Obamacare marketplaces, where people who don't get insurance through work can buy insurance. And, depending on their income, they can get help from the federal government to pay their premiums.

The family glitch deals with people who are kind of caught in between those two programs. So, if you imagine a family where, say, the mom gets insurance at work, and the insurance is affordable for her, but if she wants to buy a family plan to cover husband, cover her kids, it would be too expensive. Currently, they can't go by a different plan in the Obamacare marketplace and get eligible for federal subsidies. So that's always been known as the family glitch. There are about five million people who are in this situation.

Some of them just pay a whole lot of money to all be in the family plan in the employer, and some of them pay a whole lot of money to get a separate plan in the marketplace. And some of them are uninsured. So this is a new rule that's trying to kind of solve that problem and make it so that those people can go get subsidies if they need to buy their own insurance.

And it's long — long been recognized as a problem, right, that people have been trying to fix. We should mention there's been some Republican pushback already. And many are saying this usurps congressional authority, this should be something that goes through Congress. Are they wrong? So, the Affordable Care Act, the kind of last round of legislating was sort of lightning fast.

And there were a lot of little sloppy things that went through. And so, in the Obama administration, the officials and lawyers in the Obama administration did not think that they could solve this problem through regulation. They thought Congress needs to pass another law that said, these people should be able to go to the exchanges and get marketplace coverage. But the Biden administration has looked at it again, and they think, no, this is OK, this is an acceptable way to solve this problem with this new regulation.

It's possible that there will be some legal debate about this, some lawsuit challenging it, but it seems like the legal interpretation of the Biden administration is that they can fix this problem. And, of course, today, we saw — with President Biden, we saw President Obama was up there standing up at the podium supporting this move.

So it seems like he's come around as well. Those subsidies will run out at the end of this year, though, right? So does this fix help to fill the gap that that will leave?

So, lots of people are — have always been eligible since the Affordable Care Act became law. They have been eligible for subsidies to help them buy insurance. And what Congress did last year is, they gave them a little boost.

They made those insurance premiums a little bit more affordable. For people who are close to the poverty line, really poor Americans who work, they could get a plan for free. They don't have to pay anything. And for the first time, kind of upper-middle-class people, maybe people who own their own business and buy their own insurance who were not eligible for subsidies before, they can get some financial help too.

So, that kind of extra help, that wraparound help, that is what is set to expire unless Congress renews it. But there still will be some financial support that has been there as part of the Affordable Care Act since So, when you look at the Affordable Care Act, you mentioned there's kind of been patching holes as they go.

Are there still big holes left to patch? Who's left out? Congress tried — or Democrats in Congress were trying to patch these other big holes as part of their big Build Back Better legislation that seems to be stalled. But I would say there are two other really big groups of people who are left out.

In about 12 states, led by Republicans for the most part, there are people who are not eligible for Medicaid coverage because their states chose not to expand Medicaid program. That was optional under Obamacare, and most states have done it, but not all. And then I do think this other group is these people who technically can get insurance through the Obamacare marketplaces, but they have just found it to be unaffordable.

Insurance can be really expensive. So, we should use former President Obama's appearance to ask you this one big question, which is, we have just marked 12 years since the passage of this massive health reform law.

I mean, there's just no doubt that it has expanded insurance coverage across this country to millions and millions of Americans who didn't have the ability to get insurance before. It's also changed the nature of health insurance. If you have a preexisting condition, you don't have to worry about being left out in the cold. If you have an employer plan, you don't have to worry about an annual cap on how much your benefits will cover. There were changes to Medicare as well that improved the affordability of prescription drugs.

The list below is a selection of notable and significant changes that have been made to the Affordable Care Act through legislation, administrative action, and Supreme Court rulings. The list was guided in part by a similar document from the Congressional Research Service, listed below, and in part by the amount of debate surrounding each change.

The list is not comprehensive and is not organized in any particular order. For more comprehensive information, please see the following documents:.

Health plans that were created between and and were not compliant with the ACA's requirements, now called "grandmothered" plans, were originally supposed to come into compliance with the law at the beginning of In October , many individually insured people began receiving letters from their insurance carriers notifying them of the impending cancellation of their plans.

The plans were canceled because they did not meet new minimum coverage requirements set by the law. Under pressure from Democratic members of Congress, in November , the administration delayed for the first time the requirement that these health plans come into compliance, allowing insurers to continue offering these plans until The administration delayed this requirement for a second time in March , allowing insurers to continue offering these plans until The ACA stipulates that employers with 50 or more full-time employees must provide affordable health coverage to full-time employees beginning January 1, The administration delayed enforcement of this requirement for the first time in July The announcement from the Department of the Treasury stated that such employers would have until to provide coverage to their employees.

The administration delayed enforcement of this requirement for a second time in February The announcement stated that midsize employers with 50 to 99 full-time employees would have until January 1, , to offer health coverage. Additionally, for large employers with or more full-time employees, the requirements would be phased in: they would be required to offer health coverage to 70 percent of employees by January 1, , and to 95 percent by January 1, The administration considers 95 percent "substantially all" of a business' full-time employees.

The ACA requires every individual to enroll in health insurance beginning in If a person is uninsured for three consecutive months in a year, he or she will be assessed a penalty. The first open enrollment period for purchasing health plans on the exchanges ran from October 1, , until March 31, To avoid being uninsured for the first three months of the year and facing a penalty, individuals would have had to sign up by February 15, On October 28, , the administration announced that it would grant a hardship exemption to individuals who signed up after February 15, essentially waiving the penalty these individuals would have otherwise faced.

Prior to the passage of the ACA, most states did not offer Medicaid to low-income childless adults. Most also restricted the eligibility of low-income parents to those with incomes below the federal poverty level. When the ACA was passed, it required states to expand eligibility for their Medicaid programs to all individuals with incomes up to percent of the federal poverty level.

If the state refused to expand, the law said that the federal government could withhold all of its portion of Medicaid funding from the state. Shortly after the law's passage, 26 states sued the federal government to challenge the requirement to expand Medicaid.

The case made its way to the United States Supreme Court , which ruled on June 28, , that the provision was unconstitutionally coercive. The decision effectively made expanding Medicaid voluntary on the part of the states. The ACA establishes a 40 percent excise tax on high-cost health plans known as the "Cadillac tax. The tax was originally slated to go into effect in In December , President Barack Obama signed legislation that delayed implementation of the tax until , although many have called for a repeal of the tax entirely.

The tax was intended to be one of the major sources of revenue that would offset the costs of the ACA. The ACA requires large employers to provide their employees each year by January 31 a tax-related form that reports information on health coverage offered by the employer over the previous tax year; this information is intended to be used by employees to determine their eligibility for advanced premium tax credits.