The mandate, which requires most people to obtain health insurance or pay a tax penalty,��survived a constitutional challenge last year in the Supreme Court but remains under attack by conservatives. In July, the Republican-led House voted to delay the mandate,��although the measure is not likely to get a vote in the Democratic-controlled Senate.

Despite all that attention to the mandate, 26 percent of Americans aren’t aware of the requirement or didn’t think the law included it, according to a .��

Here are some basic questions and answers about the mandate.

Q. What is the individual mandate?

A.�� is a provision of the federal health law that requires you, your children and anyone else that you claim as a dependent on your taxes to have health insurance in 2014 or pay a penalty. That coverage can be supplied through your job, public programs such as Medicare or Medicaid, or an individual policy that you purchase. The health law is setting up online health insurance marketplaces, also known as exchanges, to help you shop for plans.

Q. Who is affected by the mandate?

A. The mandate is aimed at some of the 57 million people younger than 65 who now do not have insurance. The�� that in 2014 nearly three out of five Americans will have coverage through an employer-provided plan and 12 percent through Medicaid and the Children’s Health Insurance Program, federal-state programs that provide insurance to lower income Americans. If you have insurance in either of those ways, you are not affected. If you are in Medicare, you also .��

Q. Are there any exceptions to the mandate?

A. Yes, the government has .��Individuals who cannot afford coverage because the cost of premiums exceed 8 percent of their household income or those whose household incomes are below the minimum threshold for filing a tax return are exempt. People experiencing certain hardships, including those who would have been , also are exempt.��

Other exempt groups include prisoners, Native Americans eligible for care through the Indian Health Care service, immigrants who are in the country illegally, people whose religion objects to having insurance coverage, members of a��health care sharing ministry and individuals who experience a short coverage gap of less than three consecutive months.

��that in 2016, after the major provisions of the health law are implemented, 24 million people will be exempted from the mandate’s penalties.

Q. Why is there a mandate anyway?

A. The health law was designed to extend insurance to nearly all people, including those who have medical conditions that require expensive care and are often denied coverage today. But to pay for their care, insurance companies need to have a large enrollment of consumers, especially young and healthy people who use fewer services. The mandate was adopted to guarantee a broad base.

, the vice president of health policy at the Center for American Progress, a left-leaning nonprofit that supports the law, says it will be more effective with the mandate than without it. “This individual mandate is to keep premiums low for everyone,” he said, noting that “if you don’t have incentives for everyone to sign up for coverage then only the sick people will enroll which will drive up premiums.”

But others suggest the mandate won’t be effective because the penalties are set so much lower than the cost of coverage.

“The mandate was an attempt to get around the fact that insurance is going to become a lot more expensive for a lot of people even with the subsidies,” said , an economist with the conservative American Enterprise Institute. Antos believes the tax penalty for remaining uninsured is too low and questions the government’s ability to identify those who end up not filing taxes. “I would argue that the individual mandate is largely unenforceable and does not turn out to be this solution to the other problems that raise insurance costs for that particular group of people,” he added.

Q. How do I satisfy the mandate?

A. Health coverage provided through a job-based plan (including COBRA or a retirement plan), policies that you bought for yourself or your family, Medicare (and Medicare Advantage), Medicaid, CHIP, some Veterans Administration health programs or TRICARE coverage for members of the military and their dependents will satisfy the mandate.

If you are uninsured or thinking about switching plans, you can shop for coverage through the online marketplaces beginning Oct. 1. These marketplaces will operate in every state and the District of Columbia and will alert people with lower incomes that they are eligible for Medicaid. The marketplaces will also offer tax subsidies to help reduce the cost of premiums if your income is less than 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four in 2013) and cost-sharing subsidies that will substantially reduce the deductibles, copayments, coinsurance and total out-of-pocket spending limits for people with incomes up to 250 percent of the federal poverty level ($28,725 for an individual and $58,875 for a family of four in 2013).

Although the law takes effect Jan. 1, the initial enrollment period continues through March 31. Since people are exempted for a short coverage gap – less than three months – individuals that obtain coverage before the end of March will be exempt from the payment for that period.

Q. How do I report my coverage or exemptions to the government?

A. You will not have to report your coverage or exemptions until you file your 2014 income tax return, which won’t be due until April 15, 2015. Insurance providers will also be required to help their clients report their health coverage. The Internal Revenue Service says it will put out details later about how the reporting will work.

If your income is so low that you do not file a tax return, you are exempt from paying the penalty.

Q. What happens if I don’t get coverage?

A. If you do not have the minimum level of coverage and do not qualify for an exemption, you must pay a penalty to the IRS at the end of the tax year. The penalty for the first year is up to $95 per adult and $47.50 per child, or 1 percent of family income, whichever is greater.

The fine, however, increases over time and in 2016 will be as much as $695 per adult and $347 per child (up to $2,085 for a family) or 2.5 percent of family income, whichever is greater.

The amount you owe will be pro-rated to reflect the number of months you were without coverage.

��that 6 million people, about 2 percent of the population, will be assessed a penalty in 2016.

Q. How do I apply for an exemption?

If you are seeking an exemption for incarceration, membership in an Indian tribe or health care sharing ministry, you can apply through the health insurance exchanges or make a claim when you file taxes, according to a final rule issued by the U.S. Department of Health and Human Services. If you are claiming economic hardship or a religious exemption, you must get an exemption certificate from the online insurance exchange. If you are claiming that coverage is unaffordable, you are in the United States without proper documentation or have a coverage gap of less than three months, you can make the claim when you file your 2014 taxes in 2015.

Q. What were the issues in the Supreme Court challenge?

A. Opponents of the law argued that forcing individuals to buy insurance was unprecedented and could lead to much greater federal intrusions against individual freedoms. Supreme Court Justice Antonin Scalia, in fact, asked during the arguments on the law if such a provision meant the government could . Supporters countered that the mandate was part of a long tradition of Congress regulating business trade under the Commerce Clause of the Constitution. In the suit brought by 26 states, the Supreme Court allowed the mandate to stand because a majority of justices, in an opinion written by Chief Justice John Roberts, said it was a tax and Congress has the power to impose taxes.

Q. Where did the idea of the mandate originate?

A. The origins of the individual mandate have been controversial. Many Democrats who support the law suggest it was originally a conservative idea developed in 1989 by the Heritage Foundation’s Stuart Butler to counter liberals’ efforts to establish a single payer system and impose a mandate on employers to provide insurance. Several years afterward, Republicans used the individual mandate in a bill they offered as an alternative to Bill Clinton’s proposal to overhaul health insurance. The mandate also was incorporated as part of the Massachusetts overhaul of health insurance in 2006 under then-Gov. Mitt Romney.

Democrats later adapted the concept and pushed it as part of the congressional debate over the Affordable Care Act, despite President Barack Obama’s initial reluctance to embrace it. Whatever their prior views, most conservatives opposed the health law’s version of the mandate, and Butler made a spirited argument that the current mandate is not what he was endorsing years ago.

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In a study, , Mayo Clinic researchers surveyed more than 2,500 doctors to assess their views of different approaches to rein in��the nation’s health care costs. The doctors were randomly selected from an American Medical Association database.

Based on their findings, 59 percent of doctors believed they have some responsibility in holding down����health care costs. Only 36 percent thought they have a major role.

More than half of doctors, however, said each of five other groups carry “major responsibility:” trial lawyers, health insurance companies, pharmaceutical companies, hospitals and patients.

“What physicians are trying to tell us is that they don’t see themselves as necessarily any more responsible for health care costs than all of those stakeholders,” said Dr. Jon Tilburt, an associate professor at the Mayo Clinic and the study’s lead author. “They see themselves as a contributor, not a main contributor,” he added.

When asked about options to reduce health care costs, most doctors viewed efforts to improve the quality and efficiency of care most favorably. For example, 98 percent are enthusiastic��about efforts to promote care coordination for people with chronic diseases. Doctors were also mostly in favor of improving conditions for evidence-based decisions, including efforts to prevent corporate influence of physicians’ decisions and promoting head-to-head trials of competing treatments.

They were less enthusiastic about changing current payment models. Only 7 percent, for example, were very enthusiastic about eliminating the traditional fee-for-service payment system, while another 23 percent were somewhat enthusiastic. About a third of the physicians expressed��enthusiasm for bundled payment systems.

Though about one in three doctors think they have major responsibility, the survey shows that doctors recognize they do have a role in addressing health care costs, said Dr. Jay Crosson, the American Medical Association’s vice president of professional satisfaction, care delivery and payment.

“These are all really good things, and sometimes people don’t recognize the positivity that exists in the physician community,” Crosson added.

Tilburt also�� said the results cast a positive light on doctors.

Close to 80 percent, for example, felt that they should be solely devoted to their patients’ best interests, regardless of cost. “They will choose taking care of the patients over eliminating health care costs,” Tilburt said.

Only 16 percent of the doctors said they agreed that they “should sometimes deny beneficial, but costly services to certain patients because resources should go to other patients that need them more.” At the same time, nearly one in nine of the doctors said they need to take “a more prominent role” in limiting unnecessary tests.

Tilburt says some doctors worry the health law��might have incentives that would prevent them from doing enough for patients. “I don’t think that’s the intent of many of these reforms, but I think physicians are nervous and they need to be shown where are the win-win strategies that’s good for individual patients and for society,” he said.

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, many dealing with academic teaching hospitals, have yielded mixed results about the effects electronic health records (EHRs) have had and have drawn concerns over the adoption of health information technology. Federal officials are encouraging the implementation of such systems, arguing that it will help curb the rise in health spending by eliminating duplication of services and medical errors.

This study, however, is the largest to assess the impact EHRs have in community-based settings, including in private practices and community hospital care.

In the study, researchers analyzed and compared insurance claims data for patient care at three Massachusetts communities that adopted EHRs to six that did not. They found that outpatient spending did not rise as fast in the communities that adopted EHRs as it did in the other six. The difference in cost-growth between the two groups was about 3 percent.

“There’s a lot of anecdotal concern that EHRs are going to drive up the cost of health care. The fact that we didn’t find that is good news,” said , an assistant professor at the University of Michigan School of Public Health and the study’s lead author.

The researchers, who analyzed insurance claims data from January 2005 to June 2009, found significant savings in outpatient radiology testing. Adler-Milstein and her colleagues, however, did not find any significant savings relating to outpatient pharmacy or laboratory care, inpatient care and the total cost of care.

“It is significant because we’re looking to control the cost of delivering health care in our country. It’s a huge issue for companies, the government, and individuals. Anything that can help control the cost is going to be a good thing,” said , the board chair for the . He added, however, that the savings from adopting electronic health records may have be even greater if researchers were to analyze more recent insurance claims.

Adler-Milstein and her colleagues plan to do just that to get a better assessment. The researchers looked at data on how EHRs affected these practices’ costs only up to 18 months after implementation of them, she said. “We don’t know if it continued to perform in that way,” Adler-Milstein��said, but she suspects the savings will continue.

Chantal Worzala, the director of policy at the , added that the study showed three important aspects to making digital health records more cost efficient: financial assistance for the health care providers to buy and set up the systems, technical support to help implementation of them, and an efficient infrastructure for data exchange. “When you have all of those things, we’re getting some positive results,” she added.

The study was part of an ongoing project of the , a nonprofit corporation that offers support to health care providers with implementing electronic health records.

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That’s according to a on exemptions to the health law’s individual mandate – the law’s controversial in 2014. That rule was published Wednesday.

The health law calls for an , the federal-state insurance program for low-income Americans, by making it available to people up to 138 percent of the federal poverty level, which for individuals is $15,856 in 2013, and providing new federal funding to cover the costs for the first three years, and no less than 90 percent after that. But the Supreme Court ruled last year that states could not be forced to join in that program. About half the states so far have opted against the expansion, a concern for supporters of the law because it could leave millions of people without access to affordable coverage.

The law provides subsidies to help low-income people, but they are available only to those who earn between 100 and 400 percent of the poverty level. Individuals and families earning less than 100 percent who live in states not expanding Medicaid have few, if any, options for affordable insurance.

The final rule is similar to draft proposals from the U.S. and in January.

Those who do not have health coverage, and who do not meet the criteria for exemptions, must pay the penalty at the end of the tax year.�� The is $95 per adult and $47.50 per child, or 1 percent of family income, whichever is greater, and it increases over time.

This story has been corrected to reflect that 138 percent of the federal poverty level for single adults is $15,856.

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Joined by a panel of health policy experts at the hearing to explore ways to make health pricing more transparent, that while he views efforts to disseminate prices for health services to consumers favorably, he believes that increasing transparency has its limits. “[Transparency] starts the conversation about prices that we didn’t have in the debate over Obamacare. It’s only a start,” Brill said. “Obamacare does nothing about these prices. Nothing to solve the problem – Zero.”

In his article, Brill looked at several patients with inadequate insurance and went through their medical bills line by line to explain why their care was so expensive. Among the many reasons he identified were massively inflated charges for common drugs and services and the that bore little resemblance to true costs.

Committee Chairman Max Baucus, D-Mont.,��. “The chargemaster is like the sticker price of a new car,” Baucus said. “It is inflated, and few would ever pay it. In the case of hospitals, the list price is not just a 5, 10, or 15 percent mark-up; it can be 100 times higher. But unlike new cars, some people have no choice but to pay the chargemaster price. Who are those people? The uninsured, and the under-insured.” Baucus, who was one of the main authors of the federal health law, said it would help address some of the issues faced by the patients Brill profiled, but added that there is still more that needs to be done to get costs down.

“Let us continue to make health care more transparent and affordable,” he said. “Let us not stop working until we finish the job we started with health reform.”

Sen. Orrin Hatch, R-Utah, expressed his own concerns that the federal health law will do little to solve the high costs of care and his concerns that doctors’ fears about being sued are causing them to increase the number of tests and procedures on patients — thus driving up costs. “Unfortunately, I think the president’s health care law missed a real opportunity to address these issues,” .

, president of the Center for Studying Health System Change, added that while efforts to disseminate the prices of health services have raised awareness of the wide variation of health care costs, they have failed to lower prices to consumers. “The key to price transparency leading to lower prices for consumers is benefit designs that offer rewards to them,” he said. If enough consumers are involved, he added, there will be greater incentive for providers to improve their value.

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The study found the two groups overwhelmingly agreed that nurse practitioners should be able to practice to the full extent of their schooling and training. But doctors were less likely to��concur that advanced practice nurses should lead medical homes, which deliver team-based, coordinated care to patients. Only 17 percent of the 505 primary care physicians�� surveyed agreed with that notion, compared to 82 percent of the 467 nurse practitioners surveyed.

The two groups also disagreed��about whether��nurse practitioners should be paid equally for providing the same health services. More than 64 percent of nurse practitioners agreed with the idea of equal pay, as opposed to less than 4 percent of doctors.

The debate over the role of nurse practitioners has intensified as a result of concerns over a shortage of doctors as��an estimated 25 million people gain insurance under the health care law.�� Nurse practitioners argue they can fill some of those needs if they are granted greater scope of practice.

That debate is reflected in the study’s finding about the groups’ conflicting views��about the quality of care provided by doctors versus nurse practitioners. When researchers asked whether they felt the quality of care��provided by��physicians in exams and consultations was higher than that provided by nurse practitioners, more than 66 percent of doctors agreed, while 75 percent of nurses disagreed.

“We’ve done a lot of comparative surveys with health professionals but we’ve just never found gaps this big,” said , an assistant professor of medicine at the Harvard School of Medicine and the study’s lead author. “When we get on the ground and we survey the people actually doing the work and working together, we see some of those professionals come closer together. We didn’t observe that here.”

Donelan pointed out that most nurse practitioners in the study — approximately 75 percent — said they��are already practicing to the full extent of their training. Survey respondents who did not have this opportunity blamed their limited practice on state restrictions, hospital regulations and work setting.

During an interview, Donelan also said she was surprised by the level of disagreement in regards to the quality of care, since previous research findings have suggested little variation in the work done by�� nurse practitioners and primary care doctors.

During a , David Hebert, the CEO of the described the safety concerns raised by physicians as��a “total red herring,” and added that “nurse practitioners have been practicing safely and providing great outcomes for decades.”

, the president-elect of the , , emphasized his support for a more collaborative approach between the two clinician groups, noting their roles are not interchangeable.

Differences aside, Donelan’s study shows that the majority of practitioners��in both groups agreed that increasing the number of nurse practitioners would improve timeliness of care. However, less than a third of doctors said such an increase would boost safety or��effectiveness of care.

Nurse practitioners, on the other hand, overwhelmingly felt such an increase would improve care. Close to 81 percent, for example, thought the growth would improve access to health care for the uninsured and 77 percent��said it would result in��lower health care costs.

“As a team, this kind of inter-professional disagreement is not a good thing when we’re trying to achieve better teamwork,” Donelan said. “The conflict over roles has got to be worked out so that it’s clear for patients when they get their care.”

Moving forward, she said she hopes that both doctors and nurse practitioners will acknowledge their differences and��bridge the gaps that keep them from working together.

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The report titled, “Declining Medicine Use and Costs: For Better or Worse?” found that in real dollars, total spending on prescription drugs fell by 3.5 percent per capita��in 2012, while use of health care services, including�� visits to doctors, declined for the second consecutive year.

“The largest driver of this slowdown has been an unprecedented cluster of very popular and effective medicines losing patent protection and facing generic competition at the same time,” said Michael Kleinrock, a lead author and the company’s director of research development.

Total U.S. spending on medications last year was close to $326 billion – or $898 on a per capita basis, down $33 from 2011. Although the number of prescriptions filled in 2012 went up by 1.2 percent, that represented a 0.1 percent decline on a per capita basis, the report said.

The decrease was the first since the company began tracking such data 58 years ago, Kleinrock said. “The rate of growth for spending on prescription medicine has never been below zero,” he said.

The findings had been anticipated because of the scheduled patent expirations of blockbuster medications, such as the anti-cholesterol drug Lipitor, and the antipsychotic Zyprexa, he said.

According to the report, the patent expirations of common prescriptions resulted in a $28.9 billion reduction in spending. The increased availability of lower-cost generic drugs, which made up 84 percent of medications dispensed last year, smaller price increases and reduced spending on newer brands of medications were also factors contributing to the spending decline. The less severe cold and flu season in 2012 may also have contributed.

The report suggested there were some downsides to the reduced spending. “People are staying away from health care and not using preventive services as much,” Kleinrock said. “Many of these choices are being based on finances, and that may not be in the patient’s long-term health interest.”

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The findings are��less��upbeat��than a preliminary report , which had found��that Medicaid made a “big difference” in people’s lives. In the latest effort, researchers��dug deeper. They��compared health status, finances and use of health services between two groups of residents: some of the 10,000 people who had been selected through a lottery drawing for health insurance coverage under a 2008 limited expansion to Oregon’s Medicaid program and those who had applied but did not get accepted.

Based on analyses of 12,229 people – 6,387 of whom gained coverage – the study’s results did not show any significant difference in the levels of high blood pressure, high cholesterol and diabetes between the two groups two years after the lottery.