One year ago today, President Obama signed the Patient Protection and Affordable Care Act into law. The legislative process that led to the bill's enactment proved to be a boon to lobbyists, including former aides to key members. Industry exerted influence on the administration and members of Congress from early on in the process, and continued lobbying after the bill was passed.
In 2009 and 2010, lobbyists for some 1,251 organizations disclosed lobbying on the bill, according to the Center for Responsive Politics. Those interests included pharmaceutical firms and their trade group, the Pharmaceutical Research and Manufacturers of America, insurers like Blue Cross/Blue Shield, the American Hospital Association, the American Medical Association, universities, retailers, restaurant chains, manufacturers, telecommunications firms and labor unions.
That lobbying continues in 2011. More than 180 firms have registered to lobby for new clients on health care issues so far in 2011, 16 of which disclosed the Affordable Care Act as a specific lobbying interest, according to Sunlight's Lobbying Registration Tracker.
Health care was a major issue in the 2010 campaign, in which outside groups spent more than $454 million. The newly elected Republican majority voted unanimously for a bill dubbed "Repeal the Job-Killing Health Care Law Act," but the measure, which would surely face a presidential veto were it to pass, remains stalled in the Senate, where Democrats have the majority.
While many of the act's major changes have yet to take effect, the administration has already exempted more than 1,000 groups from one of its requirements: the mandate to provide at least $750,000 in annual coverage per enrollee. About 2.6 million individuals with so-called "mini-med" plans are affected by these waivers.
The exemptions last for only one year, and are scheduled to be phased out in 2014, when states will be required to operate exchanges -- marketplaces where individuals can purchase coverage. The waivers are designed as a temporary stopgap to prevent beneficiaries from being dropped from coverage or priced out of it.
While small businesses were among those given the reprieve this year, including Captain Elliot's Party Boats, with 10 enrollees, and Hoosier Stamping and Manufacturing Corp., with 14, waivers were also granted to huge insurance companies. Aetna received an exemption for plans that cover over 209,000 enrollees, and Cigna's waiver affected 265,000.
The political fallout from the waivers has fallen along party lines, with critics charging that they're an indication of the burdens imposed by the law and may encourage favoritism. Supporters say they indicate a flexible approach to implementation.
NOTE: In the above graph, traditional labor unions are grouped under the the "non-Taft Hartley union" segment, while the "multiemployer" category refers to collective bargaining agreements between a union and multiple employers. States were also allowed to apply for a waiver on behalf of several insurers, often because state law is at odds in some way with the federal reform act. In New Jersey, for example, insurers are required to provide affordable plans -- many of which have annual limits under $750,000.
The architects of health reform have attempted to minimize political challenges this year, front-loading the act with some of its most popular changes. New health plans can no longer deny coverage to children with pre-existing conditions; plans are required to allow children to remain on their parents' plans until age 26, and Medicare patients who fall into the so-called "donut hole" gap in prescription drug coverage get a 50 percent discount on certain covered brand-name drugs. As we reported last year, insurance companies must now also spend a certain portion of patient dollars on care rather than overhead -- a provision for which the state of Maine recently received a three-year waiver. Six other states have applied for similar exemptions. And even some of the law's selling points have had unintended consequences--rather than offer child-only insurance policies regardless of preconditions, many major insurers simply stopped offering the plans.
In recent polls, the country remains split on the law's merits, with more respondents believing the law will worsen medical care than improve it.
Four federal courts have ruled on the law, particularly the individual mandate, which requires citizens to purchase insurance or pay what is either a tax or a penalty--there is some dispute as to which term better describes the penalty. Two upheld it and two found all or part of it unconstitutional. Most recently, Florida Federal Judge Roger Vinson struck down the entire act in January on the grounds that the mandate that individuals purchase coverage was unconstitutional. That ruling was a response to a lawsuit brought by 26 states, and is now heading to higher courts for appeal.
For a sortable list of waivers received as of March 21, see below.
Joshua Hatch contributed visualizations to this story.