It has been 18 months since the passage of the Patient Protection and Affordable Care Act-better known as health care reform-and most businesses have made few, if any, changes in the delivery of their health care benefits.

However, major provisions such as penalties for not covering full-time employees and the creation of public and private health insurance exchanges to broker coverage will take effect in 2014. So employers and benefits managers will soon need to make strategic decisions including whether to offer health care at all.

"Most employers are confused right now and need more time to understand how this legislation will affect their businesses long-term," says Dorothy Miraglia, vice president of strategic benefit solutions for human resources outsourcing provider AlphaStaff Inc. in Fort Lauderdale, Florida. "There's no single answer, because offering coverage after 2014 depends on many factors, and as a general rule, companies want to remain competitive and attract the best talent."

Miraglia says that although employers are never happy about increased legislation, they understand there's a cost to doing business. "We're advising clients to look at a number of "what if" scenarios to determine where they want to be in three to five years. Right now, there are still so many unknowns with the legislation. However, we do know that in some industries with high workforce turnover, such as retail or hospitality, offering health care coverage may not be feasible in the long term."

According to a survey of 368 large companies by Towers Watson & Co., about 45 percent will rethink their long-term health care strategy during 2012, and many are uncertain how they will respond to the looming impact of state-based insurance exchanges in 2014.