Understanding How Federal Health Laws Are Published and Organized

As a physician, it is important that you keep abreast of what is required of you under rapidly changing federal laws. But to follow the law, you must be able to find it in a sea of gibberish and the strange sets of numbers and abbreviations following the common names of laws. If you have ever been frustrated by this, let’s take away some of the mystery.

Federal health law normally comes from two sources: Congress and federal agencies. Only Congress makes statutes, while agencies make administrative regulations. Statutes are initially only found by using the common name (and abbreviations and numbers that follow common names) such as the Affordable Care Act, “Pub. L. 111-48, 124 Stat. 119.” Later, portions of some of these statutes will be cut and pasted into the appropriate United States Code, (such as 42 U.S.C. 1395nn.) Regulations adopted by agencies such as CMS, OIG, and HHS will be accompanied with the citation, “Code of Federal Regulations” (i.e.,42 C.F.R 411.350) and/or the Federal Register (i.e., 72 F.R. 51012). Let's look at how these laws get these confusing abbreviations and numbers, and what they mean.

Acts of Congress
The Constitution grants to Congress the power “to make all Laws which shall be necessary and proper.”  Traditionally, these acts were printed on parchment. Congress will usually give the act a common name, such as the “Patient Protection and Affordable Care Act.”  (Although others, such as “Obamacare” may stick.)  Individual Acts of Congress, are numbered chronologically in the order in which they become law. (Public Law 111-48 is the 48^th law passed by the 111^th Congress.) At the end of the term of Congress, the various acts are placed in a sequential bound set of books called the “United States Statutes at Large,” (citations look like this: “64 Stat. 980”). But this only tells a part of the tale.                               

Acts of Congress are like grocery bags in that a single act often contains provisions for many different organizations who depend upon them - with a paragraph here on “defense,” and a section there on “taxes”- but with no organization.  Even when the acts are bound together in a volume of session laws, they are basically like bags on a shelf.  You can’t find anything - even if you know generally when the act was passed.  

How do these acts get organized so that we can find them? Simple. Somebody has to put the “groceries” away in an organized fashion. That’s where the Office of the Law Revision Counsel (LRC) of the U.S. House of Representatives springs into action and the United States Codes (U.S.C.) come into being.

The United States Code is divided into "titles" (based on overall topics) numbered 1 through 51. Title 42 contains Medicare and Medicaid statutes (for example, “Stark Law” was originally 42 USC §1395nn). The United States Code is actually a “revisionist’s history” in which the LCR editors take virtual scissors (and paste) to Acts of Congress, in an effort to carry out Congress’ intent of adding to, deleting, and modifying laws. Pieces of a single act may end up in many different volumes, and are usually completely renumbered to match the paragraphs of the U.S.C.  The Roman numerals are not important under the U.S.C. because the Code numbering system is unique, (there is only one 42 U.S.C. §1395nn, while there are many Title XVIIs used by Congress.)

While the U.S.C. is better organized for finding things than official acts or public laws, there are still problems. Until an act is placed into the U.S.C., it can be difficult for mere mortals to find something like the “Sunshine Act,” (because it is actually a small part of the ACA, not a free-standing law.)  

Adding to the misery, when Congress or an agency refer to, add to, take away, or amend a law (seemingly just to annoy us,) the government won’t use the simpler U.S.C. system. Instead, the government uses the original chapters, titles, and sections contained in the original loose-leaf “Pub. L” or “Stat.” version. (Example, the “Sunshine Act” in ACA was an Act to Amend Title XI of the Social Security Act - and not the United States Code Section where the amended statute could more easily be found.) Although necessary, this can drive a person crazy unless you actually work on Capitol Hill and cross-reference for a living.

“Alphabet Agency” Regulations
 Congress enacts major legislation, but may delegate day-to-day rule-making to what are commonly termed the “alphabet agencies,” which are actually part of the executive branch of government. CMS for example, is part of a department headed by the President’s Cabinet-level appointee, the Secretary of Health and Human Services (HHS.)  

Regulations of the alphabet agencies are first published in the federal register (see below) and in the C.F.R. volume matching the enabling statute or Act of Congress under the U.S.C. Thus, Medicare regulations are published in the multi-volume 42 C.F.R, which matches the volume number of Medicare statutes under 42 U.S.C. It is often difficult to know whether there are federal regulations in addition to a Congressional Statute. (For example, Stark Law is comprised of both Statutes 42 U.S.C. 1395nn. and three different versions of federal regulations under 42 C.F.R. 411.350 et seq.)

The Federal Register
Much like a cash register, the Federal Register is published daily and records everything the government does. The federal register is not good for finding things if you do not have the volume and page. It is said to be where the government “thinks out loud.” Anything can go into the Federal Register, including proposed rules for public comment, or public laws prior to codification. Because the Federal Register is published daily, it serves the useful purpose of providing an immediate volume and page number for government action (such as 72 F.R. 51012.)  However, because the Federal Register is only organized in chronological order, it does not match the U.S.C. or C.F.R. numbering system.  

So how do you find laws and regulations? Fortunately, we have the Internet. All of the statutes, codes, and regulations are published in full text on the Internet. To find them, it is often easiest to look up an article written by healthcare professional or lawyer that contains a hyperlink to the law discussed, then simply “click.” I can’t promise what you read will make sense, but at least you will understand what all the abbreviations and numbers mean.