Yes, we've heard about the individual mandate—er, tax. A lot. And we know about Medicaid expansion. And the free birth control. And the exchanges.

But there's a lot more to President Obama's Patient Protection and Affordable Care Act. After all, the law is 2,700 pages long. Its provisions—and overall effects—will not only change America's health care landscape, but will have ripple effects felt in all other sectors.

With regulations that began back in 2010 when Congress passed the law and dozens more being implemented through 2018, there's a lot to keep up with.

Here are some of the lesser known effects of the law.

1) Domestic violence help

Health care reform brings attention to a subject that usually doesn't get much.

As of Aug. 1, 2012, the law requires that all insurance plans cover screening and counseling for domestic abuse, a provision found under preventive services for women's health. (The other women's health benefits are more widely known and include contraceptives and routine breast and pelvic exams, pap tests and prenatal care).

The law also will prevent domestic violence from being considered a “preexisting condition.”

During a WedMD seminar in July, Health and Human Services Secretary Kathleen Sebelius praised the PPACA for bringing attention to “an issue that's off the radar.”

“It's an unfortunate equal opportunity [issue] for victims—all races, ages, ethnic backgrounds and income levels are at one point or another victims of domestic violence. And often people feel ashamed or feel they've done something to cause the violence to occur,” Sebelius said. “But this is a situation in the health insurance market. Prior to the Affordable Care Act being law, it was legal for an insurance company to deny health coverage to a domestic violence victim because she was a domestic violence victim. Because that's considered a preexisting condition. That will no longer be legal by 2014.”

For victims of domestic violence, access to health care is critical, Lynn Rosenthal, White House adviser on violence against women, wrote in a blog post.

“They need treatment for immediate injuries and ongoing care for related health problems. They need to be able to talk to their health care provider about the cause of their injuries without fear of losing their health insurance,” she said. “Most importantly, they need our compassion and support.”

2) Fake tanners will pay

This really has been a hot-button issue, so to speak: Since July 1, 2010, Jersey Shore wannabes have had to pay a 10 percent tax every time they visit an indoor tanning service.

The reason is twofold: It makes a dent in the huge price tag of reform, while discouraging indoor tanning for health reasons. Indoor tanning has been linked with skin cancers including melanoma, squamous cell carcinoma, and cancers of the eye, the Centers for Disease Control and Prevention says.

But the tax has left both tanning salon goers and owners outraged. And controversy hasn't cooled down, either.

After the Supreme Court upheld the PPACA back in June, the Indoor Tanning Association said, “As the thousands of business owners in this industry can attest, taxes have serious consequences for small businesses and their employees.

“These businesses have paid this unfair tax for the past two years,” the association said, “and the results are in: More than 3,100 businesses closed; more than 35,000 jobs destroyed. Since the tax went into effect, we estimate $145 million has been taken out of the pockets of consumers and main street businesses and remitted to the federal government.”

3) Smokers need not apply?

Under a provision of the law, smokers can be charged up to 50 percent more than nonsmokers for health insurance beginning in 2014. Regulations now allow companies to require workers who fail to meet specific standards to pay up to 20 percent of their insurance costs.

George Washington University law professor John Banzhaf helped persuade HHS and Congress to include the surcharges for smokers in the law.

“The largest totally unnecessary expense that most corporations and employers bear—which unfortunately are largely passed along to their employees—are the unnecessary medical and other costs [of] smoking,” he says.

The surcharge is an effective method of discouraging smokers. It also could result in more wellness programs aimed at reducing the number of workers who light up, Banzhaf says.

But as an alternative, some employers are deciding that the best way to avoid such costs is to not hire smokers at all. Though there are laws in place in some states prohibiting that, he argues they're rarely enforced.

4) Breastfeeding support

Breastfeeding advocacy groups are praising a provision in the PPACA that supports women who choose to breastfeed.

The provision states employers shall provide reasonable, unpaid break time and a private, non-bathroom location for an employee to express breast milk for her nursing child for up to one year after the child's birth. Employers with fewer than 50 employees are excluded if it would cause “undue hardship.”

“Mothers, babies, and employers all win with breastfeeding support,” says Joan Younger Meek, a doctor and chair of the United States Breastfeeding Committee.

“Research clearly demonstrates the value of breastfeeding for the health of women and children, and medical experts agree with the U.S. Department of Health and Human Services in recommending exclusive breastfeeding for six months and continued breastfeeding for the first year of life and beyond,” Meek says. “But returning to work can be a major hurdle for new mothers struggling to balance working and breastfeeding without the simple support measures this law ensures.”

The group argues that in addition to recognizing the health benefits of breastfeeding, the employers benefit financially, too.

Meek says with minimal effort on the part of employers to provide “a clean place in privacy” and break times, there will be an impressive return on investment for employers that provide workplace lactation support, including lower health care costs, absenteeism and turnover rates.

5) Caloric reality

Have you ever ordered a Big Mac and large fries, and thought to yourself, 'I don't even want to know how many calories this is?'

You're out of luck from now on. Now you'll be hit with caloric reality at every major chain restaurant.

The law requires restaurants with 20 or more locations to list calorie counts on menus, menu boards and even drive-thrus. The entire nutrition label also would have to be available in writing upon request.

But there's been some contention with this. Some politicians and the Food Marketing Institute say the law can prove tricky because places like grocery stores serve ready-to-eat food, but caloric information can differ between stores and regions. It also can prove costly.

In June, the FMI endorsed new legislation that will support Congress' original intent on federal restaurant menu labeling by ensuring regulatory protocols intended for restaurants are not expanded to mainstream grocery stores, thus saving food retailers and customers from unnecessary regulatory consequences costing in excess of $1 billion.

6) Mental health focus

PPACA mandates coverage parity, putting mental health treatment on par with medical care, which means deductibles, copayments and doctor visits can't be more restrictive for mental illnesses than medical and surgical coverage.

Mental health advocates praise the changes.

“I would say no single piece of legislation has had as much of a potential impact on the lives of people with mental illness as the Patient Protection and Affordable Care Act,” says Bill Emmet, a mental health advocate who works as a consultant and senior policy advisor in Los Angeles.

“The end of restrictions on coverage of people with pre-existing conditions will have a disproportionate benefit for people with mental illnesses, resulting not only in greater access to care for their mental health disorders, but—more important—in better overall health, as many will have access to health insurance for the first time,” he says.

Similarly, Emmet says, the provision allowing young people to remain on their parents' insurance plans through age 26 will have a great impact because “mental illnesses often reveal themselves just as young people are making their way in the world, and this provision will ensure they have coverage at a critical time for early intervention and treatment.”

According to the CDC, about one in four Americans has a mental illness. Additionally, people with a mental illness are more prone to other costly problems: They're more than twice as likely to smoke cigarettes and more than 50 percent more likely to be obese.

7) A pricier pizza

Papa John's CEO John Schnatter got national attention in August when he said that health reform will cause consumers to pay more for their pizza.

He estimates that the law will cost 11 to 14 cents more per pizza, or 15 to 20 cents per order. That's because under PPACA, the company will have to offer health care coverage to more of its 16,500 total employees or pay a penalty to the government.

“We're not supportive of Obamacare, like most businesses in our industry,” Schnatter said. “But our business model and unit economics are about as ideal as you can get for a food company to absorb Obamacare.”

The National Restaurant Association said the law could adversely affect restaurants' ability to maintain already slim profit margins because it requires companies of more than 50 employees to provide affordable health insurance.

Papa John's wasn't the only restaurant to bemoan costs that will come due to health reform. Chains such as White Castle, McDonalds, Burger King, Quiznos and Dunkin' Donuts all have expressed concern the law might hurt their bottom line.

8) Your FSA

A popular consumer-driven health care tactic is also changing because of the PPACA.

As of Jan. 1, 2011, flexible spending accounts may no longer be used to purchase over-the-counter drugs or medicines. Most retailers can identify items that could be reimbursed at the time of purchase, so the flexible spending account debit cards will pay for only the eligible items, Cigna says. Individuals must pay for over-the-counter drugs and medicines another way.

But the most significant change to FSAs under the law will be the implementation of the $2,500 cap on health care FSA contributions beginning in 2013, says Jody Dietel, chief compliance officer at WageWorks and executive director of Save Flexible Spending Plans, an advocacy campaign to protect the accessibility and use of flexible spending accounts.

Previously there was no cap.

“While the new cap may require an adjustment from FSA participants, the accounts are still a can't-miss savings opportunity,” she says.

Instant Insights /

What you might not know about the PPACA

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