The Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010, and amended by the Health Care and Education Reconciliation Act (HCERA) on March 30, 2010 (Pub. L. No. 111-148 (2010); Pub. L. No. 111-152 (2010)). Collectively, PPACA and HCERA are known as the Affordable Care Act (ACA). The ACA's insurance market reforms added significant compliance obligations for employers that sponsor health plans and health insurers—through amendments to the Public Health Service Act (PHSA), the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code (Code). For a discussion of these obligations organized by year, and related Practical Law resources, see Practice Note, Affordable Care Act (ACA) Overview.

In the years following the ACA's enactment, the Departments of Labor (DOL), Health & Human Services (HHS), and Treasury, which are responsible for implementing and enforcing the ACA, issued a substantial amount of guidance addressing the law's market reforms. Related guidance addressed implementation of the ACA's health insurance exchanges (see healthcare.gov). For more information, see Article, ERISA at 50: The Rise of Health Plan Compliance and Litigation: Affordable Care Act (ACA) (2010).

Now well over a decade old, the ACA has proven to be a highly controversial law. Two prominent examples are the law's much-litigated contraceptives mandate and, increasingly during 2022 and 2023, its Section 1557 nondiscrimination rules regarding plan coverage of gender dysphoria treatments. In October 2020, the Fifth Circuit characterized the ACA as "the most challenged statute in American history" and the subject of more than 2,000 legal challenges (Dierlam v. Trump, 977 F.3d 471, at *1 (5th Cir. 2020)).

In 2017, it appeared likely that the ACA would be either significantly curtailed or repealed altogether and replaced with a different law. Following his inauguration in January 2017, President Trump issued an executive order calling for delayed implementation of ACA requirements that imposed a financial burden on employers (see Legal Update, Trump Administration Orders Delay of ACA Implementation).

Also in 2017, Congress considered bills that would have significantly changed the ACA—though these bills ultimately were not enacted (see Article, ACA Repeal-and-Replace Bills in the House and Senate). However, tax reform legislation enacted in December 2017 included a provision that reduced to zero the payment for violating the ACA's individual mandate, effective beginning in 2019 (Tax Cuts and Jobs Act (TCJA), Pub. L. No. 115-97 (2017); see Legal Update, Tax Reform Is Enacted, With Significant Implications for Executive Compensation and Employee Benefits and Tax Cuts and Jobs Act (TCJA) Compliance for Fringe Benefits and Health Plans Toolkit).

In December 2018, a federal district court judge in Texas ruled on the constitutionality of the ACA's individual mandate in light of the TCJA. The district court concluded that:

(Tex. v. Azar, 340 F. Supp. 3d 579 (N.D. Tex. 2018); see Legal Update, ACA Individual Mandate Is Unconstitutional and ACA Is Invalid: Texas District Court.)

In 2019, the Fifth Circuit Court of Appeals affirmed the district court's conclusion that the ACA's individual mandate was unconstitutional (Tex. v. US, 945 F.3d 355 (5th Cir. 2019); see Legal Update, Fifth Circuit Affirms Ruling That ACA's Individual Mandate Is Unconstitutional, But Orders Do-Over of District Court's Severability Analysis). Regarding whether the individual mandate was severable from the rest of the ACA, the Fifth Circuit remanded to the district court for further analysis of the ACA's provisions.

On appeal, the Supreme Court held in June 2021 that the state and individual plaintiffs in the case lacked Article III standing to challenge the constitutionality of the individual mandate and severability of the remaining provisions (Cal. v. Tex., 141 S. Ct. 2104 (2021); see Legal Update, Supreme Court Rules Plaintiffs Lack Standing to Challenge ACA's Individual Mandate). The Court therefore reversed and remanded with instructions to dismiss the case.

Funding legislation enacted in December 2019 repealed several ACA taxes and fees (Further Consolidated Appropriations Act, 2020 (Act) (Pub. L. No. 116-94 (2019); see Legal Update, Legislation Repeals ACA Cadillac Tax and Health Insurer Fee). Most notably, the Act repealed the ACA's "Cadillac plan" excise tax. A year later, the Consolidated Appropriations Act, 2021 (CAA-21) included provisions affecting certain ACA provisions—for example, its external review requirements (Pub. L. No. 116-260 (2020); see Legal Update, Year-End COVID-19 Stimulus Legislation Includes Numerous Employee Benefit Provisions, Including Surprise Medical Billing Rules for Health Plans).

The ACA's numerous and interwoven requirements continue to pose compliance challenges for employer-sponsored health plans. In recent years, for example, plan sponsors have struggled to comply with the ACA's transparency in coverage (TiC) requirements, as implemented (PHSA Section 2715A). As a result, plan sponsors and their advisors must:

This ACA Toolkit includes a collection of resources to help plan sponsors and their advisors comply with the ACA's requirements. For a timeline of key ACA effective dates and developments (2010 to present), see Effective Dates and Summary of Key Provisions Under the ACA Chart.