The historic health overhaul that President Obama signed on Tuesday (in advance of further "fixes" in a reconciliation bill) will make sweeping changes in our health system. They include new consumer protections, expanded coverage of the uninsured, penalties for people and businesses who don't buy insurance, attempts to control rising costs, and Medicare savings and new taxes to pay for it all. Here is a year-by-year look at what's in store, assuming final Senate passage later this week of a package of amendments to the landmark bill both chambers already have passed:
Adults who can't get coverage because of a pre-existing medical condition can join a high-risk insurance pool (this is an interim step pending the launch in 2014 of competitive health insurance marketplaces and premium subsidies).
Insurance companies will have to issue policies for children with pre-existing conditions. They will not be allowed to revoke existing policies if people get sick. Lifetime limits on coverage will be banned in new coverage and annual limits will be restricted. Preventive services will be fully covered, with no co-pays or deductibles. Coverage will be available for dependent children until they turn 26.
People in the Medicare prescription drug program will receive a $250 rebate as the first step in closing the coverage gap, or "doughnut hole," that requires them to pay full freight after they have spent $2,700 on drugs. The gap would be phased out entirely by 2020.
Certain small businesses will start getting tax credits to offset up to 35 percent of the cost of insuring their employees. That will rise to 50 percent in 2014.
Plans must have "an effective appeals process" for decisions and claims. States will get grants to set up programs that help consumers with complaints or questions about health insurance. The federal government will set up a website to help people in different states figure out their insurance options.
The first tax increase kicks in: A 10 percent tax on indoor tanning services.
Medicare changes will include free annual wellness visits; little to no cost-sharing for preventive care, like immunizations and cancer screenings; bonuses to primary care doctors and general surgeons; a new Center for Medicare and Medicaid Innovation to test ways to provide better, more efficient care; and, the start of a phase-out of overpayments to private Medicare Advantage insurers. People in the prescription "doughnut hole" will receive discounts on prescriptions.
There will be new money for primary care services and new incentives to encourage doctors to join together in "accountable care organizations." The government will track re-admission rates at hospitals and impose penalty fees on hospitals with the highest rates.
This is when higher taxes will begin for households with income above $250,000 and individuals above $200,000. The Medicare payroll tax on earnings above those amounts will rise from 1.45 percent to 2.35 percent. Unearned income above those amounts, such as dividends, will now be subject to a 3.8 percent tax.
In addition, maximum contributions to pre-tax Flexible Savings Account contributions will be limited to $2,500 a year (down from the current $3,050 for individuals).
There will be a new 2.9 percent excise tax on medical devices.
Medicare will sponsor a national pilot program on "payment bundling" -- paying hospitals, doctors and other providers based on patient outcome, not services provided.
More consumer protections begin. Insurance companies will not be able to deny policies to anyone based on their health status or to refuse coverage of a treatment based on pre-existing health conditions. Their ability to charge higher rates to people based on age, geography, family size or tobacco use will be limited. Annual limits on coverage will be abolished.
Each state will open a health insurance exchange, or marketplace, for individuals and small businesses without coverage. People will be able to comparison shop for standardized health packages. There will be a multistate private plan available nationwide, supervised by the U.S. Office of Personnel Management. Tax credits will be available to make insurance and care affordable for people who make too much to qualify for Medicaid, but have incomes below 400 percent of poverty.
Most people will be required to buy insurance coverage or pay penalties that start at $95 in 2014 and rise to $695 or 2.5 percent of income in 2016. Employers with 50 or more workers who do not offer coverage will have to pay annual fees.
Medicaid eligibility will increase to 133 percent of the poverty level ($14,404 for individuals) for everyone under 65 (when they qualify for Medicare).
A new Independent Payment Advisory Board will be formed to come up with ways to lower Medicare costs and promote better care. The recommendations will go to Congress and private insurers.
This is when the most controversial new tax begins, a 40 percent excise tax on insurance companies and plan administrators for any family plan that costs more than $27,500. The tax applies to the cost above that threshold. There are higher thresholds for retirees over 55 and plans that cover workers in high-risk jobs.
The new system will have reduced the number of uninsured people by 32 million, according to the nonpartisan Congressional Budget Office. That will leave an estimated 23 million uninsured, one-third of them illegal immigrants. Coverage of legal residents too young for Medicare (under age 65) will be 94 percent, up from 83 percent now.
Sources: House Energy and Commerce Committee, Speaker's Office, WhiteHouse.gov, Kaiser Health News, Congressional Budget Office