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What's next for health care following Obama's reelection?

With President Barack Obama winning reelection, more provisions of the Affordable Health Care Act (ACA) are set to roll out over his second term. Some aspects of the law have already been put in place, including allowing children up to the age of 26 to stay on their parents' health care plans and free preventive services for women.

Eventually, the ACA will require all Americans to have some form of health insurance, whether through a state plan or one offered by their employer. Companies with over 50 people will be required to offer insurance to their employees.

"For most Americans [the next phase of the law] means almost nothing," Robert Field, professor of law at Drexel University's Earle Mack School of Law and professor of health management and policy at Drexel's School of Public Health in Philadelphia, said to "Most people get coverage through their employer and will continue to do so."

The act has already been implemented in several ways since being signed by President Obama in March 2010.

A Patient's Bill of Rights was introduced in 2010, and in 2011, people with Medicare were allowed to get free preventive services and also receive a 50 percent discount on brand-name drugs that fell into the Medicare "donut hole," a term for medication fees that fell between the initial coverage limit (maximum government would pay) and the catastrophic coverage threshold (maximum a patient is expected to pay).

This year, Value-Based Purchasing program (VBP) gave financial incentives to hospitals to improve the quality of care, and paperwork and administrative costs were reduced by requiring standardize billing. Health plans were also asked to adopt and begin enforcing rules for the electronic exchange of health information. For a full timeline of what has been and what will be implemented, visit

But, there are still some parts that haven't been rolled out, and with Obama back as commander-in-chief, Americans can expect that the plan should go according to schedule. Coming up in January 1, 2013, the number of Americans who have preventative care will be increased through additional funding for states that decide to cover preventative service to their citizens for little or no cost. Medicare professionals will also be payed using payment "bundling," where they will receive a flat rate depending on the kind of care provided for each case instead of having to bill each individual procedure to Medicare. Primary care doctors will also get an increase in pay and will receive 100 percent of Medicare payments for 2013 and 2014 cases. States will receive two more years of funding to help cover children who are not eligible for Medicaid in Oct. 2013.

In 2014, several provisions will kick in, most notably the requirement that all Americans get health insurance or face a tax penalty. Also, companies won't be able to discriminate based on pre-existing medical conditions or gender, the latter meaning insurance companies can't charge men and women different rates. That year, the act will also eliminate annual limits on insurance coverage and make sure people who participate in clinical trials will be covered by insurance.

As for the mandating insurance, Field explained that on a person's 2015 income tax claim, he or she will see a line asking if they have maintained insurance and asking for some sort of proof. If the person has no insurance, a fee will be assessed. The first year will be $95, and then the fee can be up to $695.

Probably the most affected group will be young people who do not opt into their employer's plans either because they feel they don't need insurance or they need the money because they are starting out, Field said. This group is the most likely to forgo insurance if offered it.

The bigger cost will be put on employers, who will be required to offer insurance plans if they have 51 employees or more. Field said most large companies already provide coverage, but the change will be bigger for medium-sized companies. Still, the fees assessed for not complying are rather mild, Field said. He estimated that each employer will have to pay on average about $15,000 to ensure an employee and his or her family.

"It's based on what happens to the people that you don't cover," Field said. "If people buy insurance from the exchanges, the employer will have to pay a penalty based on the subsidies the government has to provide the employee."

There is some concern that the fees employers have to pay may be transferred either to the employee or the customer through more expensive services and goods. Whether the ACA will cut into salaries is unknown right now.

"That's hard to predict right now," Field said. "They might. There are more workers than there are jobs."

However, Field points out that employers can use insurance costs for their employees as a business expense that they can write off as a tax deduction. For small businesses, the credit is up to 50 percent of the employer's contribution, and for small non-profit organizations, they can claim up to 35 percent.

On January 1, 2014, the affordable insurance exchanges will be introduced. These state-run programs will allow people to buy individual coverage without regard to their health status. Tax subsidies will be given to the middle class, referring 100 percent to 400 percent of the poverty line who are not eligible for other affordable coverages, so health care can be more affordable, according to In 2010, that 400 percent of the poverty line corresponded to about $43,000 for an individual or $88,000 for a family of four.

There will be four levels of plans: Platinum, Gold, Silver and Bronze, ranging from 60 percent coverage to 90 percent coverage of health care costs. So far, no price points have been set, but they will be based on actuarial values - basically, how much medical expenses you can expect to pay depending on the services you get, Field explained.

"There's a lot of logistical issues," Field said. "For people with lower income up to 100 percent of the poverty level, there are supposed to be subsidies to help you pay. However, that doesn't guarantee that (the plans) will be affordable.

Patients who make less than 133 percent of the poverty line -- approximately $14,000 for an individual and $29,000 for a family of four -- can enroll in Medicaid, and states will receive 100 percent of funding to provide this for three years and then 90 percent for the following years.

People however will be required to take their employer's plan if they are offered it first. Field said that chances are, those plans will be at least "as good if not better" than anything the state offers. If you are unemployed or are not eligible for coverage, you can buy into the state plan or show evidence of financial hardship so you do not have to pay for insurance.

Regardless of who offers it, all insurance plans will be mandated to cover some basic tenants, including hospital stays, tests, doctor's visits, basic procedures and emergency room visits. Nothing is really different from what is covered now by insurance plans, except for the requirement to provide preventative services which includes contraception, Field pointed out. That requirement is has caused much controversy.

As for the doctors, in 2015 physicians will be paid according to quality of care, not according to the number of patients seen.

This could potentially lead to a lack of medical professionals and a higher demand. Field said that in the case of Massachusetts, whose health care plan is the model for the ACA, health services did see an increase of primary care visits for the first few years. But, this isn't necessarily a bad thing, Field argued. That measure could increase the demand for nurse practitioners rather than physicians. Certain clinics in Massachusetts are run with nurse practitioners and don't have doctors on staff.

"It should be seen as a good thing that (nurses and other medical professionals) would be more in demand," Field said.

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