By TOM HAYNIE

On March 23, 2010, President Barack Obama signed into law the most comprehensive and complex health care reform in the history of the United States, if not the world. With a sweep of the pen, he put in motion a program that will be felt by nearly every American citizen and resident and every employer in the country.

The document behind the law contains more than 2,400 pages of legal description and complexity. To attempt to cover it all in a brief article would be futile. However, there are some major provisions that can be briefly acknowledged and the potential impact described.

Nevertheless, it is inevitable that the act will likely go through many legislative and judicial modifications over the next few years. What it looks like today may be far removed from what it will become: a toothless kitten, a multiheaded monster or something in between.

The law will implement in several annual installments, which began last year:

2010 -- The Patient Protection and Affordable Care Act was signed into law March 23. Small businesses (25 or fewer employees) may be eligible for as much as a 35 percent tax credit for heath insurance costs depending on the number of employees and their average income.

Jan. 1, 2011 -- Calendar year plans were prohibited from having lifetime maximums or restrictive annual maximums beginning six months after enactment. Adult children to age 26 must be covered on their parents' insurance if elected. There are no pre-existing condition exclusions for children under 19. Over the counter medical expenses may not be reimbursed by flexible spending accounts, or FSAs, without a prescription.

Jan. 1, 2012 -- Covered employers will be required to submit reports on the quality of care in their health care plans to the Department of Health and Human Services. This requirement is not applicable to grandfathered plans.

March 23, 2012 -- Twenty-four months after enactment of PPACA, plan administrators will be required to provide plan participants with a uniform summary of benefits based on standards developed by HHS for all plans.

Jan. 1, 2013 -- A $2,500 cap will be imposed on FSAs. The cap will be indexed to inflation beginning in 2014. Medicare taxes increase on Jan. 1. Costs for retiree drug expenses for which subsidies are received will cease to be deductible for the plan sponsor and will become taxable.

Jan. 1, 2014 -- Many major provisions of the plan will implement in 2014.

Other than plans that have been grandfathered, minimum essential coverage for plans provided by employers with 50 or more employees means that the health care plan must pay for at least 60 percent of the medical expenses (after deductibles and co-pays) of the employee and family and cannot cost more than 9.5 percent of the employee's total household income. However, there are not yet provisions to help employers determine the employee's household income.

There will be no exclusions based on pre-existing conditions and no annual limits. Automatic enrollment will be implemented for employers with more than 200 full-time employees. Auto enrollment could be implemented sooner if HHS issues regulations earlier.

A $2,000 penalty per full-time employee (in excess of 30 employees) will be assessed on employers with more than 50 employees if employers do not offer health coverage and they have at least one full-time employee receiving a subsidy for health care coverage. Other penalties apply to employers that do offer health coverage if at least one full-time employee receives a subsidy ($,3000 per employee on subsidy).

States will establish small business health options programs or "SHOP" exchanges.

Every individual will be required to obtain health care insurance. Employees who's household income is less than four times the federal poverty level ($89,400 for a family of four or $43,560 for a single person in 2011 (Federal Register, Vol. 76, No. 13)) and whose share of the employer's plan premium falls between 8 and 9.5 percent of household income can choose to enroll in an exchange.

In April 2011, as part of the budget deal, Congress repealed the requirement that the employer must offer a free choice voucher equal to the amount the employer would have paid under the employer's plan. Employers were concerned that younger, healthier employees would opt out of the employer plan and choose a state plan, thus leaving higher risk employees in the employers' plans and increasing employer costs.

Group health plans must certify their compliance with electronic transaction standards that will apply.

Jan. 1, 2017 -- States may allow large employers to participate in exchanges.

Jan. 1, 2018 -- A 40 percent excise tax on the administrator of high cost or "Cadillac" plans will become effective.

The most recent data from the Census Bureau shows that only 69 percent of all U.S. employers offered health insurance to their employees. The accompanying chart shows the source of health insurance if provided.

The goal of health care reform is to provide affordable insurance coverage to all individuals regardless of their employment status. Employers are divided as to whether their health care costs will rise, decrease or remain about the same.

The law will have disparate impact on employers depending on their size, the makeup of their work force, the average wages of their employees and whether they currently provide health care coverage. Many employers believe the intent of the health care reform bill, to bolster the employer-based health care system, will do just the opposite and undermine it.

A number have determined that they may drop health care coverage altogether and pay the penalties, a decision they believe would be less expensive than having to increase costs and provide coverage to all of their employees. This decision is primarily made by small- to medium-sized employers with an employee base whose average wage rates are low.

They argue that they will not be able to afford the additional cost of coverage and would find paying the penalties to be more cost effective. They may elect to realize the lower cost as additional profits or they may use the savings to increase wages to attract better qualified workers.

Some larger firms that currently offer coverage only to certain classes of employees may decide to reduce wages and provide coverage to all employees. This may create a negative effect by preventing them from attracting better qualified employees because of the lower wage rates. Still other large firms with relatively high-paid employees whose current health care costs are low may see no change in the coverage they offer or the cost of the coverage.

On the other hand, competition may have a greater impact on the decision to provide or not to provide health care coverage than any other factor. Employers will look to competitors in their industries to see if providing coverage creates a competitive advantage that they may not be willing to concede.

It is well-established that the beneficiary of health care reform, other than underinsured and uninsured individuals will be the medical industry. With as many as 32 million additional insured individuals, the demand for medical services will increase substantially. This benefit will present itself as a mixed blessing and may come at considerable cost as well.

If the law implements essentially as written, there will necessarily be a significant demand for skilled medical providers at all levels. There could be a serious shortage of physicians and other medical practitioners. Like them or not, health maintenance organizations provide lower cost care now, but providers within HMOs are on very tight schedules, may be short staffed and frequently have a high patient load. Throwing millions more patients into the system could have serious unintended side effects.

Doctors and nurses are not created overnight. The years of training and education necessary to develop a health care force sufficient to absorb the additional demand must be started now. Colleges, universities and training academies should be gearing up for the influx of new candidates. The funding for these expensive educations will need to come from somewhere (the government? private industry?).

On the other hand, if the law is significantly gutted and the anticipated increase in demand evaporates, what will we do with all of these new providers? Will their education and training be wasted or will the increase in supply create downward pressure on pricing for medical services? In the latter case this may result in increased demand as more people without insurance or who are are underinsured may be able to afford better care.

In between the employer and the insurance companies are the brokers who currently bring together and coordinate all of the players in the health care symphony. Brokers currently have a well-defined and significant role in bringing health insurance from the carrier to the individual through the employer.

Under reform, the broker's role will change substantially. While the reform itself may not affect the broker's role to a large extent, the establishment of state health insurance exchanges may have a very significant impact on the way they do business.

A large number of individuals going directly to a health insurance exchange will bypass the broker. Of necessity, brokers may have to take on a more consultative role to provide customers with guidance on managing their way through the complex maze of reform.

Medium-sized employers will be caught in the middle. They are too large to take advantage of government exemptions and subsidies for small employers, and may be too small to be able to absorb the additional cost of reform. This may force them to consolidate their employees through a staffing agency like Manpower.

A staffing agency that provides employees to several client companies is the sole employer of all of these employees. As such, the agency may have the purchasing power to acquire mandated insurance coverage for all employees and families at a reduced cost that can be passed on to individual clients.

What is likely to happen if the law does not change? Supporters believe that the employer mandates will result in more employers offering coverage to their employees. They point to the Massachusetts law that went into effect in 2007 where there was an increase in employer-offered health insurance in 2007 and 2008.

Critics say that employers may drop coverage and opt for the less expensive penalties forcing employees into state exchanges. They are particularly concerned that reform will stifle growth of employers with just under 50 employees who may decide against hiring additional workers even if they are needed.

The Congressional Budget Office estimates that by 2019 approximately 3 million fewer people will have employer-based coverage. At first there should be an increase in the number of people covered by employers, however, as the state exchanges come into existence and employers begin dropping coverage, people will flock to the exchanges. The CBO estimates that employers will pay nearly $52 billion in additional assessments between 2014 and 2019, money that will go to help defray the cost of purchasing coverage through the exchanges.

Will the law change between now and 2014? That depends on a variety of events. If the administration and the legislature remain in the hands of Democrats, probably not. However, if there is a significant shift of political power after the next major elections there could be drastic changes in store. In the meantime, employers, employees and insurers must decide whether they will march forward as though the law will survive or wait for the dust to settle.