ACA Overview

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Overview (last updated 9.24.17)


The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010; this was the bill passed by the Senate 60-39 on December 24, 2009, and the House 219-212 on March 21, 2010. The Health Care and Education Reconciliation Act (HCERA) was passed by the Senate 56-43 and House 220-207 on March 25, 2010 (because it used the budget reconciliation process, it did not have to attain 60 Senate votes to surmount a filibuster). HCERA reconciled some of the differences between the original House version (passed 220-215 on November 7, 2009) and Senate version. Together these two pieces of legislation are conventionally referred to as the Affordable Care Act (ACA) even though there is no single piece of legislation with that name.

Statute and Regulations

Full Text Statutes

ACA consisted of two separate laws: HR 3590 was the Senate version of health care reform, and HR 4872 was the reconciliation bill that made some fixes in the law to make it palatable to the House of Representatives. The reconciliation combined text is also available.

Regulations and Guidance

The U.S. Department of Health and Human Services lists all ACA regulations issued to date on various issues (e.g. coverage for children under 19). It also has maintains a Requests for Comments page on draft regulations and comment deadline dates. American Benefits Council maintains a comprehensive listing of official source documents related to PPACA regulations. The Congressional Research Service has issued a series of reports regarding ACA regulations:

Impact of Regulation

  • The Regulatory Burden of the Affordable Care Act. “The Affordable Care Act (ACA) was signed into law nearly six years ago. Since that time, 106 regulations have been finalized to implement the ACA. These regulations will cost businesses and individuals more than $45 billion and will require approximately 165 million hours of paperwork in order to comply. In addition to these regulations, hundreds of guidance documents regarding the ACA have been published by various federal agencies during this time as well. However, more regulations—and additional costs—are still to come. Regulations for one of the most expensive and burdensome provisions of the ACA—the ‘Cadillac Tax‘—have yet to be written. Guidance documents were published last year, but a final rule may not be published for a few more years given that the implementation date of the tax was recently delayed until 2020. The cost of each ACA regulation published so far has averaged $426 million and required 1.6 million hours of paperwork.” (American Action Forum, 2.15.16)
  • Paperwork Burden. Federal law requires agencies to estimate the paperwork burden created by rules and regulations. This publication reflects a survey of the new burdens created by the Affordable Care Act by the agencies’ own estimates. All in all, the annual burden of compliance is estimated to be 189,882,836 man-hours, while the one-time burden is projected to be 78,957,868 hours. (Ways and Means, Education, and the Workforce, Energy and Commerce Committees, May 2013)

Basic Structure


The ACA has 10 titles, each of which has an overarching focus/purpose (Table 2).

  • Title 1. Quality Affordable Coverage for All Americans. Purpose: reform and expansion of private health insurance.
  • Title 2. The Role of Public Programs. Purpose: Medicaid expansion and reform (see ACA and Medicaid for details).
  • Title 3. Improving the Quality and Efficiency of Health Care. Purpose: Medicare changes and delivery system reforms (see ACA and Medicare for details).
  • Title 4: Prevention of Chronic Disease and Improving Public Health. Purpose: prevention, wellness and public health.
  • Title 5: Health Care Workforce. Purpose: improving workforce quality and quantity.
  • Title 6: Transparency and Program Integrity. Purpose: fraud and abuse control; clinical comparative effectiveness; transparency, physician payment sunshine act, and more.
  • Title 7: Improving Access to Innovative Medical Therapies. Purpose: allowing follow-on biologic drugs in the U.S. pharmaceutical market.
  • Title 8: Community Living Assistance Service and Supports (CLASS Act). Purpose: cash assistance for temporarily or permanently disabled Americans (now repealed).
  • Title 9: Revenue Provisions. Purpose: financing about half of the cost of the full ACA (see ACA and Taxes for details).
  • Title 10: Strengthening Quality Affordable Health Care for All. Purpose: amendments to Titles 1-9, including Indian Health Reauthorization Act.

Selected Titles

Title 1. Title 1 is the most detailed, including:

  • Immediate Improvements in Health Care Coverage.  Examples include: a) elimination of annual or lifetime limits on coverage; b) required coverage of clinical preventive services without cost-sharing; and c) required coverage of young adults up to age 26 on parents’ policies.
  • Health Insurance Market Reforms. Examples include: a) ten “essential” health benefits required in most health insurance policies; b) “minimum loss ratios” setting limits on insurer administrative expenses and profits; c) review of health insurance premium rate increases greater than 10%; d) limits on age and gender as allowable premium rating criteria.
  • Creation of Health Exchanges. This includes provisions for establishment and operation of federal and state Exchanges, along with the provision of income-related tax subsidies to reduce the premiums and cost-sharing associated with health plans offered on the Exchanges.
  • Risk Amelioration Provisions (3Rs). This includes risk adjustment, risk corridors and reinsurance
  • Individual Mandate. This includes provisions specifying who is liable for mandate penalties and the amounts of such penalties (which steadily increase by year).
  • Employer Mandate. This includes provisions specifying which employers are liable for mandate penalties and the amounts of such penalties (which vary depending on whether the employer offers no coverage or coverage deemed “unaffordable”).

Title 3. This title also has a number of provisions, the most familiar being:

Title 4. Some of the most familiar features of this title include:

Title 5: Health Care Workforce Provisions

  • Innovations in the Health Care Workforce.
    • Creates a National Health Workforce Commission to help define national priorities, goals and policies.
    • Provides planning and implementation health care workforce development grants to states focused on education, training and retaining individuals for health careers/related industries.
    • Establishes National/State and Regional Centers for Workforce Analysis. Provides grants for the development of information to describe and analyze the health care workforce. State and regional centers collect, analyze and report data. Enhanced grants to be provided for longitudinal evaluations.
  • Increasing the Supply of the Health Care Workforce. 
    • Provides Loan Repayment and Scholarships for medical school, primary care practice, nursing, pediatric specialists, child and adolescent mental and behavioral health, public health workforce (in federal, state and local/tribal health) and allied health workers in public agencies. Mid-career workers will be eligible for scholarships to upgrade their education.
    • Provides grant opportunities to Nurse Managed Health Clinics (NMHC) for comprehensive primary health care services or wellness services to underserved or vulnerable populations. The NMHC must be associated with a school, college, university or department of nursing, FQHC or independent non-profit health or social services agency.
    • Eliminates caps on Commissioned Officers in Public Health Service Regular Corps; Revises Regular Corps and Reserve Corps and renames the Ready Reserve Corps— responds to public health emergencies both foreign and domestic.
  • Enhancing Health Care Workforce Education and Training. Health Professional Training Program Grants will be awarded to enhance education and training for primary care; direct care workers; general, pediatric and public health dentistry; geriatrics; mental and behavioral health; nursing and advanced nursing; and community health workers. Grant opportunities to include support for residencies and internships; need-based financial assistance for traineeships/fellowships; preparation of faculty; medical home demonstrations; joint degree programs for inter-disciplinary and professional training; and pre- and postdoctoral training.
  • Supporting the Existing Health Care Workforce. Revises funding allocations to assist schools in supporting programs of excellence in health professions education for underrepresented minority individuals and schools designated as centers of excellence.
    • Continues support for Area Health Education Centers that provide community based training and education, interdisciplinary training and continuing education, and prepare individuals to more effectively provide health services to underserved areas and populations.
    • Makes revisions to the Nursing Workforce Diversity Grants Program to increase nursing education opportunities for individuals from disadvantaged backgrounds, including stipends for diploma or associate degree nurses to enter a bridge or degree completion program and scholarships/stipends for accelerated nursing degree programs, pre-entry preparations, advanced education preparation and retention.
    • Establishes a Primary Care Extension Program to provide support and assistance to educate primary care providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services, and evidence-based and evidence-informed therapies and techniques. Requires the Secretary to award grants to states for the establishment of Primary Care Extension Program State Hubs to coordinate state health care functions with quality improvement organizations and area health education centers.
  • Strengthening Primary and Other Workforce Improvements.
    • Expands access to primary care services and general surgery services by offering incentive payment programs of 10% in a health professional service area.
    • Includes toward the determination of full-time equivalency for graduate medical education cost time spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is primarily engaged in furnishing patient care in nonpatient care activities.
    • Reallocates unused residency positions to qualifying hospitals for primary care residents for purposes of payments to hospitals for graduate medical education costs.
    • Revises provisions related to graduate medical education costs to count the time residents spend in nonprovider settings toward the full-time equivalency if the hospital incurs the costs of the stipends and fringe benefits of such residents during such time.
    • Directs the Secretary, when a hospital with an approved medical residency program closes, to increase the resident limit for other hospitals based on proximity criteria.
    • Requires the Secretary to: (1) award grants for demonstration projects that are designed to provide certain low-income individuals with the opportunity to obtain education and training for health care occupations that pay well and that are expected to experience labor shortages or be in high demand; and (2) award grants to states to conduct demonstration projects for purposes of developing core training competencies and certification programs for personal or home care aides.
    • Authorizes the Secretary to award grants to teaching health centers for the purpose of establishing new accredited or expanded primary care residency programs. Allows up to 50% of time spent teaching by a member of the National Health Service Corps to be considered clinical practice for purposes of fulfilling the service obligation.
    • Requires the Secretary to make payments for direct and indirect expenses to qualified teaching health centers for expansion or establishment of approved graduate medical residency training programs.
    • Requires the Secretary to make payments to teaching health centers that operate graduate medical education program. Payments shall be provided for direct expenses and for indirect expenses to qualified teaching health centers that are listed as sponsoring institutions by the relevant accrediting body for expansion of existing or establishment of new approved graduate medical residency training programs.
    • Requires the Secretary to establish a graduate nurse education demonstration under which a hospital may receive payment for the hospital’s reasonable cost for the provision of qualified clinical training to advance practice nurses.
  • Improving Access to Health Care Services.
    • Provides appropriations for federally qualified health centers to serve medically underserved populations.
    • Requires the Secretary to establish through the negotiated rulemaking process a comprehensive methodology and criteria for designation of medically underserved populations and health professions shortage areas.
    • Reauthorizes appropriations for the expansion and improvement of emergency medical services for children who need treatment for trauma or critical care.
    • Authorizes the Secretary, acting through the Administrator of the Substance Abuse and Mental Health Services Administration, to award grants and cooperative agreements for demonstration projects for the provision of coordinated and integrated services to special populations through the co-location of primary and specialty care services in community-based mental and behavioral health settings.

Title 6. Some of the most familiar features of this title include:

General Pressures on Health Spending

Cost Containment Provisions

Provisions Leading to Higher Total Spending and Price Pressures

Bill Summaries

Other Materials

  • Organizational Charts
    • Joint Economic Committee (2010)static2.politico
  • Citizens’ Council for Health Freedom (2012)


  • Glossaries
  • Frequently Asked Questions.
    • DHHS has a site on PPACA implementation FAQs.
    • Read the Q & A from NAHU’s health reform webinars.
  • Fact Checkers
  • Timelines.
  • Payment and Delivery System Reforms.
    • Commonwealth Fund. Summary of Select Affordable Care Act Payment and Delivery System Reform Provisions. (May 2015) Extensive list includes payment reform, changes in organization of health care delivery (with provisions related to “primary care transformation”), and changes to workforce policy.
    • Transforming the Health Care Delivery System: Proposals to Improve Patient Care and Reduce Health Care Costs. Thought to be an analysis Congress heavily relied upon when drafting the ACA. “The dynamics in our health system affect the care that is delivered in both the public and private sectors. In many cases, changes to federal health programs like Medicare activate and pave the way for system-wide changes. The proposals contained in this document set forth ideas on ways to revise payment systems and policies in the Medicare program to promote higher-quality, and more cost-effective care and to reduce fraud, waste and abuse throughout the health system.” (Senate Finance Committee April 29, 2009)
    • The Triple Aim: Care, Health, And Cost. Donald M. Berwick, Thomas W. Nolan and John Whittington. (Health Affairs, May 2008)
  • History. 
    • Disclosed in the WikiLeaks Podesta email releases of October, 2016, this memo (dated 10.1.08), from Jeanne Landrew, describes the aims of the transition team for candidate Barack Obama’s health reform agenda.
    • Behind the Veil: The AARP America Doesn’t Know. “This report highlights AARP’s increasing reliance on the ‘for-profit’ sale of insurance, particularly health insurance, and the underlying implication for this storied ‘non-profit’ organization. In conducting the research, one of the central questions became: Why would AARP aggressively advocate for the Democrats’ health care law last year which contained nearly one half-trillion dollars in cuts that independent analysts said would negatively impact seniors’ access to affordable health care services? The report also details the Democrats’ health care law’s significant cuts to Medicare Advantage (MA) and how the interplay in the marketplace between MA and Medigap will increase Medigap sales. This will have a direct, significant, and positive impact on future profits at AARP. Also troubling is the report’s central finding: The Democrats’ health care law, which AARP strongly endorsed, could result in a windfall for AARP that exceeds over $1 billion during the next 10 years.”  (House Ways and Means Committee, 3.29.11)
    • Obama’s Deal. April 13, 2010 transcript of PBS Frontline program detailing dealmaking that occurred during creation of the Affordable Care Act.

The Basics

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