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affected premiums.

* Medical-loss ratios. This rule, which kicked in after January 2011, says health insurers must spend at least 80 percent of premiums on medical care and quality improvements or return the difference to consumers or employers. The law resulted in August rebates averaging $96 for about 55,000 Nevadans covered through five of the state's 40 insurers.

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Two changes that didn't make the cut

Some provisions of Obamacare never made it into practice, either because they were fiscally unsustainable or impractical. Here are the two biggest measures stripped from the bill so far:

* Community Living Assistance Services and Supports (CLASS) Act. Under this voluntary long-term disability program, enrollees who paid benefits for five years would have been entitled to $50 or more a day in payments for in-home care. Supporters said the law would help Americans afford nursing care and draw attention to the importance of long-term care funding. Critics called the regulation a gimmick to raise revenue that would hide the costs of Obamacare. Health and Human Services head Kathleen Sebelius killed the act in October 2011 after the U.S. Centers for Medicare and Medicaid Services said the program wouldn't generate enough revenue to pay for benefits, and would cost the federal government more than it took in after 2025.

* Paperwork. Obamacare included a provision requiring businesses to file 1099 miscellaneous income forms with the IRS anytime they spent more than $600 with any vendor business, rather than just independent contractors. The idea was to boost tax compliance - and revenue for the implementation of Obamacare - by discouraging under- reporting and fraudulent deductions on 1099 income. But critics said the rule would do little to close the noncompliance gap, because it was unlikely that major suppliers such as Staples or Costco were hiding income from client businesses. The regulation would also have flooded the IRS with millions more tax documents each year. Congress repealed the rule, and the president signed the repeal into law, in spring 2011.

Some reform provisions are already in full force and affecting consumers, insurers and health care markets:

- Children and pre-existing conditions. As of 2011, insurance companies can no longer cite pre-existing conditions to limit or deny benefits or coverage on insurance policies for kids under 19. The Obama administration credited the rule with guaranteeing coverage to 17 million American kids with pre-existing conditions. In practice, though, the law has had unintended consequences. A 2011 study from Politico found that insurers in 34 states stopped selling child-only insurance policies, and 20 states - including Nevada - no longer have any carriers selling child-only policies. The reason? Insurers said parents would wait until their children got sick to buy coverage, and premiums for all policyholders would spike to cover the costs of a less-healthy membership pool.

- Insurance for dependents. After September 2010, kids could stay on their parents' insurance plans until age 26. Observers agreed the law had an effect: Numbers from the Centers for Disease Control and Prevention showed an 18 percent drop in 2011 in the share of young adults without health coverage. Health policy experts at both liberal and conservative think tanks credited the decline to this provision of Obamacare. But some policy watchers said the number of insured young fluctuates with the economy, which improved from 2010 to 2011 and may have given twenty-somethings more access to jobs and employer-sponsored health care. Plus, some young adults who could have qualified to buy plans on their own through work likely opted to stay with mom and dad's plan to save on premium costs and boost take-home pay, so there are doubts about whether the regulation reached truly uninsurable kids. And a 2012 report from human- resources consulting firm Towers Watson found that dependent- coverage rules boosted overall premiums 3 percent and have encouraged increasing numbers of employers to stop covering dependents altogether.

- No out-of-pocket costs. Obamacare prohibited providers and insurers from charging patients for routine physicals, vaccines, mammograms and other preventive care and screening after 2010. But the rule applies only to insurance policies written since it took effect. There's little research available on how this provision has affected premiums.

- Medical-loss ratios. This rule, which kicked in after January 2011, says health insurers must spend at least 80 percent of premiums on medical care and quality improvements or return the difference to consumers or employers. The law resulted in August rebates averaging $96 for about 55,000 Nevadans covered through five of the state's 40 insurers. Some provisions of Obamacare never made it into practice, either because they were fiscally unsustainable or impractical. Here are the two biggest measures stripped from the bill so far:

- Community Living Assistance Services and Supports (CLASS) Act. Under this voluntary long-term disability program, enrollees who paid benefits for five years would have been entitled to $50 or more a day in payments for in-home care. Supporters said the law would help Americans afford nursing care and draw attention to the importance of long-term care funding. Critics called the regulation a gimmick to raise revenue that would hide the costs of Obamacare. Health and Human Services head Kathleen Sebelius killed the act in October 2011 after the U.S. Centers for Medicare and Medicaid Services said the program wouldn't generate enough revenue to pay for benefits, and would cost the federal government more than it took in after 2025.

- Paperwork. Obamacare included a provision requiring businesses to file 1099 miscellaneous income forms with the IRS anytime they spent more than $600 with any vendor business, rather than just independent contractors. The idea was to boost tax compliance - and revenue for the implementation of Obamacare - by discouraging under- reporting and fraudulent deductions on 1099 income. But critics said the rule would do little to close the noncompliance gap, because it's unlikely that major suppliers such as Staples or Costco were hiding income from client businesses. The regulation would also have flooded the IRS with millions more tax documents each year. Congress repealed the rule, and President Obama signed the repeal into law, in spring 2011.