Hundreds of people across Missouri have been taking part in rallies and seminars this week to mark the first anniversary of the controversial Affordable Care Act. Under the legislation, federal health officials say, Missouri has been awarded more than $47 million for programs ranging from expanding health center services, to closing the donut hole for seniors, to cracking down on "unreasonable" increases in insurance premiums.

The health law, according to Dr. James Kimmey, CEO of the Missouri Foundation for Health, is the most far-reaching piece of domestic legislation since Social Security. It's significant that President Barack Obama was the first president to nudge Congress into passing this broad health care law.

There was plenty of cheering among Democrats when the legislation was approved and signed. But on today's first anniversary, the scene is more muted, perhaps because Republicans and tea party activists have voiced opposition and more than half the states have launched legal assaults against some provisions of the act. Moreover, Obama has so many other controversial issues on his plate, including involvement in the war in Libya, that he apparently hasn't had much time to pause and celebrate what some regard as his greatest achievement to date as president.

Notwithstanding the programs and peace of mind supporters say the reform legislation should be bringing to many in Missouri, a poll shows that voters in general have yet to fully embrace all provisions of the new health law. About half the state's residents continue to oppose it, while 30 percent are for it, and the other 20 percent aren't sure what to make of the law.

'huge Step Forward'

Still, the act has plenty of backers, says Amy Smoucha, head organizer of Missouri Jobs for Justice. She's also part of Missouri Health Care for All, a statewide coalition of 129 organizations that has tried to publicize the law's benefits. The legislation, Smoucha says, marks the first time Missourians will have significant protection in health care. She cites the law's guarantee of access to health insurance, caps on out-of-pocket expenses and tax credits for middle-class families and small businesses. She calls these benefits "a huge step forward when middle class and working families have experienced rising health care costs and shrinking coverage."

In response to talk about repealing the legislation, Smoucha (left) says, "We must implement the law, let it work for our families and evaluate and fix any parts that miss their mark."

One thing the law did fix was access to health insurance among young adults. Alaina Khothuis, 23, the daughter of a professor at the University of Missouri Columbia, is proof of that. She had taken her health care for granted until last summer. Just out of college, she sprained an ankle, went to get treatment and discovered to her surprise that she no longer had health insurance.

Her mother, Shari Khothuis (left), says the insurer didn't immediately inform the family that it was dropping Alaina from coverage after she graduated from college in the spring.

"We did not receive a notice until September, and it was by email," the mother says. She is thankful that the health reform law allows parents to keep their children on the family policy until age 26. "My personal preference is universal health care for all. But the act is the best that we can get," she adds.

Another thankful mother is Elizabeth Miller whose son, Michael Miller (left), 24, had been without health insurance for two years because of a pre-existing condition. "But when the ACA became law," Elizabeth Miller says, "we were able to get him insured on my fiance's health insurance. He has a unique policy that allows for insurance for domestic partners," and includes children of partners, she says.

High Risk Pool Insurance Has Few Takers

Nancy Bollinger, executive director of a small nonprofit organization in St. Louis County, is another who embraces the law. A heart attack years ago made it difficult for her to find health insurance that was affordable to her and her employer. Under the new law, Missouri and other states were required to set up special pool insurance programs for certain persons with pre-existing conditions.

Initially, the monthly premium for her policy was $680, but it has since dropped to $544 after Missouri reduced the rates because it got so few takers under the old rate. State insurance officials say the federal legislation has given Missouri enough money to accommodate about 2,300 in the special high-risk pool for people like Bollinger. So far, fewer than 300 people have signed up, presumably because of the cost of premiums.

Dr. Amy Richard (left), a chiropractor in Webster Groves, had never used her insurance because she had never suffered a serious illness. But that changed last summer when she noticed a rash on her chest and the diagnosis was inflammatory breast cancer. She not only worried about the illness itself but about the insurance industry's use-it, lose-it habit of dropping coverage the minute a customer files an expensive claim. The new health law prevents insurers from doing this, and Richard says, "It gives me peace of mind to know that I will have coverage in the future and won't have to worry so much about the financial strain and stress."

The health law also has helped more small businesses offer health insurance for employees. One example is Mokabe's Coffee House a popular cafe on South Grand at Arsenal. Inside, a picture of President Barack Obama hangs on one wall. Cafe owner Mo Costello, who has been in business for 19 years, said he is pleased that Obama pushed for the federal law to offer a 35 percent tax credit to small businesses to offset the cost of employee health insurance.

"I feel strongly about the universal health care issue, and the right of people to health insurance," Costello says.

Awaiting The Next Increase

Another small business owner who says the tax credit matters is Arlene Zarembka, a lawyer in Clayton. She estimates her law firm will reduce its tax bill by $1,000 compared to what the firm would be paying without the Affordable Care Act.

While this helps, Zarembka (left) adds that the cost of health insurance continues to rise and is her firm's second highest cost of business.

"I shudder awaiting my next rate increase from Anthem," she says.

To slow premium costs, the federal government should stop exempting health insurance companies from anti-trust laws, Zarembka says. In Missouri, she says, it would help if the state Department of Insurance had authority over rate increases. Federal health officials say the Missouri Department of Insurance expects the health reform provisions to give it more muscle to review health insurance premiums in Missouri. The state agency intends to use grants from the Affordable Care Act to develop a review process for premiums in both individual and small group markets, federal officials say.

Checks For Prescription Drugs

The biggest news for Missouri's elderly has been $250 checks to offset prescription drug expenses. The federal government says nearly 83,000 elderly Missourians have received the checks to cover some of their costs for prescriptions, known as the donut hole coverage gap.

The check has eased some of the worry of Sharon Hollander (left). But she says closing the hole itself is the answer. In the meantime, she praises the next provision of the reform law, the 50 percent discount seniors will get for covered brand-name prescriptions when they reach the donut hole.

Another Medicare recipient, Mary Clemons (right), is pleased that the law gives a break to seniors by offering them free annual checkups without requiring a co-pay. She describes that benefit as a proactive approach to wellness, a way to keep seniors out of the hospital.

"Now I can go to a doctor when I am feeling well rather than waiting until I am sick," she says. "My doctor may find that I have a condition that can be treated before it becomes life threatening and costly."

Critics Say Competition Is Key

For all the praise it gets, the Affordable Care Act also has plenty of critics. One is Missouri Sen. Jane Cunningham (right), R-Chesterfield. She was instrumental in getting voters to pass a referendum against the requirement that people buy health insurance or pay a penalty - the so called "mandate." She says the issue won't be settled without a ruling from the U.S. Supreme Court. She notes that more than half the nation's state attorneys general have signed onto Florida's a suit again the health law. "We, of course, wanted (Missouri Attorney General Chris) Koster to join the, but he failed, which made us all scratch our heads."

Another critic is Sen. Rob Schaaf (left), R-St. Joseph. He says the solution is to inject more competition into the health-care system so that consumers know the price of treatment. "As soon as we start doing that, the cost of health care will start coming down, and it will be affordable to everyone," he says, adding that he, too, opposes the insurance mandate.

In January, the Missouri Foundation for Health released a poll showing that Missourians disliked some provisions of the health reform law but favored others. The group's CEO, Dr. James Kimmey (right), explained some of those voter misgivings in an earlier interview with the Beacon.

Most respondents in the MFH survey applauded tax credits to small businesses; a crackdown on price-gouging; preventive measures, such as breast and colon screening; subsidies to help some low- and moderate income people buy insurance; and insurance access to people having pre-existing conditions. The surprise is that only 22 percent of those polled were aware that these benefits were in the law, according to the foundation.

In a statement accompanying the poll, the foundation's health policy chief, Ryan Barker, says the more Missourians learned about the law, the more they embraced it. That apparently explains why 50 percent said they opposed the law in a poll in January, down from 55 percent in a similar poll last August. Barker says the new results point to "subtle shifts in attitude as residents learn more about how the law will impact them personally."