The Patient Protection and Affordable Care Act was signed into law by President Obama on March 23, 2010, with provisions of the bill scheduled to be phased in through January 2018.

The next round of significant and material changes is scheduled to take effect January 1, 2014. It’s important for business owners to consider these changes — including tax relief, premium subsidies and the availability of “state insurance exchanges” — as we prepare our operating plans for the coming years.

Like many small businesses in the D.C. area that provide goods and services to the federal government, we are small enough to purchase insurance through state insurance exchanges but our average salaries are too high for us to qualify for tax relief.

Under the law, tax credits are currently available to qualified small businesses through 2014. Businesses with up to 25 full-time employees who earn average wages of $50,000 or less excluding the owner and who contribute at least 50 percent of the total premium can qualify for a subsidy. The subsidy works on a sliding scale — employers with fewer workers earning less money may qualify for a larger subsidy.

As a health care professional, I have always made employer sponsored health insurance a business priority. However, over the past several years it has become an increasingly difficult benefit to maintain, manage and afford.

In an effort to protect this benefit for my employees, our company implemented a high deductible plan with a health spending account (HSA) two years ago, which has helped to slow the effects of premium increases. That being said, as a small business we will remain exposed to significant rate increases from year to year until we either grow to a size that would provide a more even distribution of risk or have access to another risk pooling arrangement.

It is this uncertainty and my desire to continue my commitment to employer sponsored health insurance that makes me and millions of other small businesses supportive of the exchange concept.

These state-based exchanges, or pools, were included in the law partly because of a concerted effort by organizations such as Women Impacting Public Policy (WIPP), a national nonpartisan public policy organization, of which I am a member, advocating on behalf of nearly one million women owned businesses and representing 59 business organizations.

Small businesses have been waiting for years for a pooling mechanism to facilitate the purchase of affordable health insurance for their employees. To that end, it is critical that the proposed exchanges are structured in a way that most effectively combines small businesses together to maximize their buying power, avoid adverse selection and reduce actuarial risk, making the small business segment more attractive to insurers.

Given our current benefit design, there is some concern that under health reform, the limit on the amount that can be deposited in an HSA tax-free will be significantly reduced, which could potentially be disadvantageous to my employees and their families. However, this risk could be mitigated if we are able to purchase insurance with similar benefits through an exchange for a lower premium.

As our nation continues to focus on job creation and employment, it is critical to recognize the direct correlation between health and productivity, and the role that access to affordable health insurance plays in promoting a healthy and sustainable workforce.

Lisa Firestone is president of Managed Care Advisors, Inc. in Bethesda.