Health reform turns two: after passage of the Affordable Care Act, the work--and the criticisms--persist.

• Author: King, Martha
• Position: HEALTH REFORM: SPECIAL REPORT

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NCSL tracks state actions on federal health reform closely. You can learn more about federal regulations, state legislation, Medicaid, insurance reform and more at www.ncsl.org/healthreform. Several NCSL health staff contributed to this package of stories to the two-year anniversary of the Affordable Care Act.

Health reform passed by Congress in 2010 is probably the most controversial domestic legislation of the Obama administration to date.

As the Affordable Care Act marks its second anniversary this month, opponents continue to vilify its complex--and feared costly--provisions, while backers praise its groundbreaking attempt to extend health coverage to nearly all Americans.

The U.S. Supreme Court will hear arguments this month challenging the law's requirements that everyone carry insurance and that states expand their Medicaid programs. Rulings are expected by summer.

State lawmakers, meanwhile, have their hands full trying to comply with the law's various provisions. Legislatures considered more than 900 bills related to the act in 2011, and more than 200 have been introduced so far in 2012.

The cost of implementing federal health reform concerns state lawmakers who have had to deal with unprecedented budget shortfalls in the last four years. They are keenly aware of the millions of Americans who currently qualify for Medicaid but are not yet enrolled, and who will seek coverage once the individual mandate kicks in. Unlike the newly eligible, these millions will not qualify for the law's generous federal match.

The Supreme Court's pending action "casts a dark cloud over dozens of state legislatures, which will adjourn prior to the decisions on key provisions of the law," says Alabama Representative Greg Wren (R), co-chair of NCSL's Health Reform Implementation Task Force. "Clarity has been sought, yet the maze of lawsuits, elections, session schedules, and deep political divides cast dark clouds over ai1 the implementation mandates."

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Despite what some see as an unprecedented overreach by the federal government into health care, the law has made some changes that are less controversial and in some quarters, welcome. It requires coverage for young adults up to age 26 and those with pre-existing conditions; offers health insurance tax credits for small businesses; and relief for seniors reaching the coverage gap under Medicare Part D. It also requires insurance plans to spend at least 80...