Hurdles to an Oct. 1 deadline

From passage to implementation, the Affordable Care Act has encountered bumps along the way

March 23, 2010: President Obama signs the Affordable Care Act into law. The broadest changes to the U.S. health-care system in decades, it is intended to provide coverage to millions of uninsured Americans through new private insurance marketplaces, called exchanges, and an expansion of Medicaid. The White House immediately begins the massive task of implementing the law.

Spring 2010: An office to build the insurance exchanges and other parts of the law is created directly within the office of Health and Human Services Secretary Kathleen Sebelius.

May 11, 2010: David Cutler, a Harvard professor and health adviser to the 2008 Obama campaign, sends memos to White House officials — including one dated May 11 to then-director of the National Economic Council Larry Summers — warning that the administration needs an outside expert to oversee work on building insurance exchanges and other facets of the massive law.

July 2010: launches for the first time, without the enrollment function.

Sept. 23, 2010: The law bars insurance companies from refusing to cover children with preexisting conditions, from dropping people who get sick and from placing lifetime limits on coverage. It allows people to stay on parental health plans until age 26.

Jan. 1, 2011: Insurance companies are required to spend 80 to 85 percent of premiums on medical care and health-care quality improvement; as a result, many Americans begin to receive annual refunds. Preventive care becomes free under Medicare, the federal insurance program for people 65 and older.

Early 2011: The Centers for Medicare and Medicaid Services — a large federal agency spread among locations in the District, Bethesda and Baltimore — takes over responsibility for building the insurance marketplaces from the unit that had reported directly to Sebelius. As a result, the work of building the federal exchanges becomes fragmented.

February 2011: The White House official overseeing work on the law, Nancy-Ann DeParle, is promoted and begins to spend only a small fraction of her time on it. Her successor is Jeanne Lambrew, who worked on the law’s passage in Sebelius’s office and, years earlier, had worked on health reform under Bill Clinton.

Spring 2011: The White House tells HHS employees they may not publish diagrams showing how a federal health exchange could work, known as “concepts of operation,” out of concern that the complicated image could be seized as ammunition by the law’s Republican foes.

Late November 2012: Standards for insurance coverage under exchanges aren’t proposed until after Obama’s reelection, just before Thanksgiving, and do not become final until February 2013. Another regulation that spelled out important rules for insurance premiums was also delayed until after the election.

Dec. 19, 2012: Obama meets at the White House with top aides, including Sebelius, and tells the group that the health-care law, and implementing it well, will be the most important thing in his presidency.

Late 2012 to January 2013: Staff within the Center for Medicare and Medicaid Services’ Center for Consumer Information and Insurance Oversight, in charge of implementing much of the law, says that the time frame for building the federal exchange was becoming so compressed that there would not be enough time to conduct “end to end” testing of

July 2: The Treasury Department announces it will delay the requirement that employers of 50 people or more provide insurance starting in 2014 by one year; only a handful of top Senate and House Democrats are told about the decision roughly half an hour before it becomes public.

July 18: Two Blue Cross Blue Shield Association lobbyists tell aides to House Minority Leader Nancy Pelosi (D-Calif.) that they are concerned there is not enough time to test the Web site.

Aug. 17: The project’s largest contractor, CGI Federal, sends a memo to about a dozen staff members inside CMS, updating the schedule of work on the federal exchange. Less than a month and a half before launch, the memo says the company’s portion of work on the exchange is 55 percent complete.

Sept. 5: White House officials visit the Center for Medicare and Medicaid Services for a final demonstration of Some staff members worried that it would fail right in front of the president’s aides.

Oct. 1: People begin shopping for health insurance on, but the site crashes after a relatively small number of insurance-seekers attempt to create accounts that are a first step toward exploring health plans.