According to estimates from the Congressional Budget Office (CBO), the ACA will eventually extend coverage to nearly 32 million uninsured Americans, leading to a net reduction in the uninsured population of 22 million. The legislation includes numerous provisions scheduled to take effect over an eight-year period. Some of its major provisions, along with their implementation dates, are enumerated below:

Effective Upon Passage:

• Created the non-profit Patient-Centered Outcomes Research Institute to independently research the effectiveness of different medical treatments.

Effective on June 21, 2010:

• Adults with pre-existing medical conditions became eligible to join a temporary “high-risk pool” of insurance applicants after uninsured for six months.

Effective on July 1, 2010:

• Created the National Prevention, Health Promotion and Public Health Council.

Effective on September 23, 2010:

• Insurers prohibited from imposing lifetime dollar limits on essential benefits.
• Dependents permitted to remain on their parents’ insurance plan until the age of 26.
• Insurers prohibited from excluding pre-existing medical conditions for children under 19.
• Insurers prohibited from dropping policyholders once they become ill.
• Implementation of mandatory appeals processes for coverage and claims on all new health insurance plans.

Effective on January 1, 2013:

• Additional income tax of 0.9 percent levied against single individuals making in excess of $200,000, in excess of $250,000 if married and filing jointly, or in excess of $125,000 if married filing separately.

Effective on January 1, 2014:

• Insurers prohibited from discriminating against, or charging higher rates for, any individual based on pre-existing medical conditions.
• Individuals who do not obtain health insurance subject to annual penalty of the greater of $95 or 1 percent of their income. The fine then rises to the greater of $695 or 2.5 percent of income by 2016 with an established “family” penalty limit of $2,085. Exemptions on the basis of financial hardship or religious objection allowed.
• Deadline for the state establishment of public health insurance exchanges to trade and buy policies.
• Subsidization of insurance premiums available for individuals with income up to 400 percent of the poverty line.
• Expansion of Medicaid availability to all individuals with income up to 133 percent of the poverty line.
• New excise taxes levied against pharmaceutical companies based on market share, most medical devices, and health insurance companies based on market share.

Effective on January 1, 2017:

• States may apply to the Secretary of Health and Human Services for a waiver of certain sections of the law (including the individual mandate) provided that the state develops an alternative plan that “will provide coverage that is at least as comprehensive” and “at least as affordable” for a “comparable number of residents.”

Effective on January 1, 2018:

• All existing health insurance plans must cover approved preventive care and checkups without co-payment by the policyholder.
• 40 percent excise tax on high-end insurance policies introduced.

The most controversial provision of ACA is undoubtedly the “individual mandate” portion of the law, which requires all citizens to obtain health insurance and inflicts a monetary civil penalty on those who opt not to. Although the provision was not scheduled to take effect until January 1, 2014, it was easily the most litigated and contested issue following the passage of ACA.