ACA Changes, Repeals, Modifications, Clarifications…Thus Far

Readers and health care stakeholders may find it interesting (if not frustrating), that as of the date of this blog post (August 6, 2014) there have been a grand total of 42 changes* made to the Affordable Care Act (ACA) since its signing into law on March 23, 2010.  Furthermore, the changes have not originated from a single source; nor have the changes been influenced/encouraged by a single political party.  The fact is, of the 42 changes to date, 24 have been made unilaterally by the President; 16 resulting from acts of Congress; and perhaps the most notable – 2 – by the Supreme Court of the United States (SCOTUS).  After taking last week off to enjoy a nice family vacation, I return this week to summarize these important changes.

Although not the first of the 42 changes, the SCOTUS rulings/changes set the tone for much of the future implementation of several key ACA provisions.  In its anxiously anticipated, landmark June 28, 2012 ruling, SCOTUS ruled…

  1. The ACA’s Medicaid expansion had to be voluntary rather than mandatory.  This left the decision as to whether to expand Medicaid availability to childless adults whose incomes fell below the threshold for ACA subsides in the hands of each state’s governor; and
  2. The individual mandate was a tax, and therefore constitutional/legal to implement.  This ruling also meant that from a legal standpoint, individuals could choose whether to meet the ACA’s requirement to have health insurance or not; the choice to not have coverage resulting in an increasingly punitive fine.

Much of what congress did in its 16 changes was technical “clean ups” and funding cuts.  Perhaps the most significant and impactful of congress’ changes was the repeal of the requirement that businesses report to the IRS, via 1099, ALL vendor transactions totaling $600 or more in a year. 

Also noteworthy was the repeal of the ACA’s CLASS Act or Community Living Assistance Services and Supports program.  CLASS was a government funded, employer administered long term care insurance program that was described by one congressional representative as a “Ponzi scheme of the first order”. 

Last, but certainly not least, and the most recent of the congressional changes, was the elimination of caps on deducible amounts attributable to small group health plans.  Originally, the ACA placed a cap of $2,000 (individual) and $4,000 (family) on small group plans, which, among other things, would have severely impacted the offering of Health Savings Account (HSA) qualified plans.

Many of the changes announced by the President and/or agencies such as the IRS and HHS were delays of various provisions, for various reasons.  Delays affecting the employer mandate (twice), employer mandate related reporting, the individual mandate, offering ACA compliant plans, and the availability of small group coverage through the exchanges/marketplaces have had the most impact on affected parties.  But the change that many people are talking about, and two separate U.S. circuit courts recently ruled on (see ) is the one allowing premium subsidies to flow to individuals purchasing coverage on a federally facilitated exchange/marketplace, despite the law’s specification that such subsidies are only available “through an exchange established by the State…”.

A significant delay that many anxiously await for a conclusion on, is the non-discrimination rules.  This provision once/if implemented by HHS would place significant penalties on employers with fully insured plans that discriminate (either by employee premium amounts or plan eligibility) in favor of so called highly compensated individuals (HCI’s).  Originally set to take effect in 2010, this provision is on hold pending the release of IRS regulations.

* Source: Galen Institute; see