The health care law has been on a roller coaster ride since its passage one year ago, moving forward with implementation plans even as opponents throw up legal and legislative challenges to stop it in its tracks. At Kaiser Health News, we wondered where these moving parts might be in March 2012, at the measure's two-year mark. So we asked players and experts from across the nation what they thought the landscape would be like – and, in their view, should be like. They discussed issues ranging from the new insurance marketplaces called exchanges to the future of accountable care organizations: combinations of hospitals, doctors and sometimes insurers. Here are their edited responses:
Bill Hazel - Secretary of Health and Human Resources in Virginia, one of the states challenging the constitutionality of the law.
We will be extraordinarily busy. We will probably have designed the new marketplaces – the exchanges – as best we can, but we will still have to go back to the General Assembly for implementation. We'll have a whole lot to do in a very short period of time. Unless something changes with the law, we will have the whole issue of getting the benefit exchange up and running. Getting it implemented will be a technical challenge.
Currently, everything is in a state of flux. We suspect that aspects of the bill will change with this Congress and we also have the lawsuits, which likely will not be resolved by this time next year.
In Virginia, we've authorized the Bureau of Insurance to enforce the law as it stands today. We've been told by the General Assembly to plan an exchange and bring it back for approval next year. And we have money budgeted to build an infrastructure that will allow us to determine eligibility for both the formerly eligible and the people newly eligible for Medicaid. We're trying to streamline and automate the process and are well into that.
Lloyd H. Dean - President and CEO of Catholic Healthcare West
Over the next year you'll see more ACOs and more sharing of data and integrating ourselves with other providers.
We'll begin to see the cost curve bending in the organization. Last year we were one of the first organizations in the country to launch a major accountable care organization – I like to call it a triumvirate, with CHW, Blue Shield of California and Hill Physicians. That's been a success: We've reduced hospital admissions by 22 percent; we've reduced the length of stay and hospital days by almost 13 percent. A year from now we'll be relatively far along in the path of implementing our new electronic health record.
What's important here is that we're not sitting on the sidelines waiting for something to happen in Washington, D.C., before we all get in the game. When you look at us a year from now, we'll be more efficient, with better medical outcomes and better alignment with our physicians and others in the communities we serve.
Tom Goldstein - Attorney, co-founder of SCOTUSblog
One year from today we should be waiting for a ruling from the Supreme Court. The courts of appeals should have decided the constitutionality and upheld the statute of the reform bill by this fall and the cases should have proceeded quickly to the Supreme Court for expedited consideration.
During the appeals process, I will be watching whether a court invalidates the individual mandate and therefore the entire law. I think that there will have been vigorous dissents on the Commerce Clause so the issue of the fate of the law will still be unsettled by the time it gets to the Supreme Court. But once the cases have been argued, I think the conventional wisdom is that the statute will be upheld because the justices have taken a very broad view of Congress's power.
Wendy Schiller - Associate Professor of Political Science and Public Policy, Brown University
The health care message is going to get more complicated for the American voter in 2012. The Republicans clearly ran against the health care bill in 2010, but they're going to have to come to the table in making cuts to Medicaid and Medicare in the next year. You can't even get close to cutting the deficit if you don't cut entitlement spending. It's going to be much harder for the Republicans to make this a key issue in the 2012 elections.
In Obama's favor, a lot of the provisions of the health care bill will kick in. And the more people who actually benefit, the more entrenched these programs will be. As we see with Medicare and Medicaid, once a program is entrenched and voters see clear benefits, the [program is] almost impossible to get rid of.
Independents are the only [voting] group you're really looking at in terms of health care. And the issue will be the battles for the key states -- Ohio, Pennsylvania, Illinois, Michigan, Florida and California. It's really, ironically, going to be a much more localized issue than it is a national issue. From this point forward, it's the implementation of the health care act that will matter much more for Obama in 2012 than the passage of the act itself.
Ceci Connolly - Senior Adviser, McKinsey Center for U.S. Health System Reform
What I will be watching are the Republican presidential primaries and the CMS innovation center. I want to be keeping an eye on that, because I feel strongly that the real transformation in health care will come from the private sector. So I am very eager to see if and how quickly seed money from the innovation center can foster truly significant change. Will the innovation center grants help us find a way to deliver the right care at the right time for the right price?
I think what has been striking about health care to date here in the U.S. is this: We have amazing one-off success stories. We can point to them dotting the landscape but the real question is, can and will those be replicated or expanded? That's why I'm eager about the private sector, but also hopeful that at least this grant money could help nudge it along.
Steven E. Wojcik - Vice President, Public Policy, National Business Group on Health
By March 2012, we hope to convince Congress to adopt medical liability reform that limits how much providers pay in non-economic damages and restricts attorneys' fees. The administration has signaled that it is open to changes, and there's a significant gap in the health care law to reduce the unnecessary, added costs we all pay for defensive medicine.
We also will have made sure health care payment reforms pilot projects called for in the health law get implemented quickly and widely throughout the Medicare program because we want to be paying for outcomes and quality not just care. We expect to work through the regulatory process to make sure "consumer directed" or high-deductible health plans are allowed to be offered as rules get drawn up for new insurance exchanges. These plans are the key to getting health costs under control.
Sarah James - Analyst, Wedbush Securities
One of the insurance industry's main focuses in the next year of health care reform is medical loss ratio [provision, which requires insurers to spend 80 percent of premium revenues on medical care] and how it may change. There's a push to change the definition of MLR to exclude brokers' commissions. If it goes through, it would be very positive for the managed care plans. Also, removing broker commissions from premium revenue would make it easier for plans to stay in states like Maine.
Also, there's the impact of exchanges. Each state's exchange could be different, creating some favorable markets and some less favorable markets. Another negative aspect is the potential repeal of the individual mandate, which fines people for not having insurance. If you remove that, you're more likely to have healthy people stay out of plans.
Meanwhile, a lot of insurers are diversifying to areas outside the U.S. with a particular interest in Asia, and also in the technology area. There's a lot of federal money coming into health information technology.
Katie Mahoney - Director of regulations, U.S. Chamber of Commerce
By March 2012, we hope to persuade Treasury to clarify how the health law bans employers from giving richer health benefits to high paid executives than their employees. We want the regulations to be made clear so employers are not unfairly accused of discriminating against their employees.
The Chamber also hopes to convince regulators to define "essential benefits package" in a less extensive way so it doesn't make the cost of coverage unaffordable. We don't want every desirable benefit to be required, because that will drive up costs.
The Chamber expects to work through the regulatory process to make sure that employers continue to have important flexibility to design workplace wellness programs. The health law expands the incentive amount that employers' can offer to workers for participating in wellness programs beginning in 2014. The Chamber also hopes to convince Congress to change the health law's provision that bars employees from using their flexible spending accounts from buying over-the-counter medications unless they have a doctor's note.
Howard Bedlin - Vice President for Public Policy and Advocacy, National Council on Aging
Seniors will become more aware of what's in it for them, because there's still a lot of confusion and misunderstanding about the implications of health care reform in general. If you've been looking at the Kaiser tracking polls, many people don't even know it's law.
People will gain a greater understanding of what this means, the fact that some of the Medicare reductions did not cut benefits or impede access to care. They did not cut payments to doctors. They will have access to physicians and may have better access to primary care physicians. Hopefully more will avail themselves of preventive services, annual wellness visits.
I do think an important issue next year, particularly in the fall before the elections, will be what the trends are with regards to Medicare Advantage plans. It will vary a lot by geographic region. What happens next year will have particular implications for folks. We're talking about a quarter of beneficiaries.
I anticipate that sometime next year, the CLASS program [voluntary long-term care insurance] will be made available for people to sign up. That will affect baby boomers more than seniors, because there will be a work requirement. But seniors who are working will be eligible to sign up. It will provide some meaningful benefits for folks that will be interested in it.
Thomas Johnson - President and CEO, Medicaid Health Plans of America
By March 2012, we want to have regulations on accountable care organizations that ensure managed care plans can play a major role in these new payment and delivery systems.
We hope to convince more states to carve drug benefits back into Medicaid managed care. Many states now exclude drug benefit from being managed by their Medicaid managed care plans.
We hope to have more guidance on how Medicaid will interact with the insurance exchanges. There should be a recognition that Medicaid health plans have experience in dealing with this population with complex medical histories, and we think our health plans are well suited to be in the exchange. Medicaid health plans should have the option of offering coverage to small business and individuals in the exchanges. We don’t think there should be any barriers that limit their participation.
David Godfrey - Medicaid director, Minnesota
I think we will have made a lot of progress in terms of trying to put the pieces together necessary at the state level to prepare for the creation of the exchanges, although a lot of work will still need to be done on that. But we'll have a framework, I believe. Also (we'll be) pursuing different grant opportunities through the ACA, and also begin thinking about policy and program redesign and response to the ACA as well. There's a lot of interest in administrative simplification. We think this is an opportunity for that. There's still a lot of work to be done in that area, and we're still waiting for a lot of the guidance from CMS in terms of just what our programs need to look like by 2014.
The backdrop to all this is we have a significant budget deficit, and there's going to be incredible pressure in trying to find cost savings in the Medicaid program in response to that and just trying to manage those pressures but still moving forward and putting into place the building blocks we need for 2014.
Rose Ann DeMoro - Executive Director, National Nurses United
(What will you be doing this time next year?) Same thing we've been doing: Fighting for a single payer health system, Medicare for all. We're working with [Sen.] Bernie Sanders in Vermont on his campaign for single payer.
It's incumbent on us to figure out a way to pay for it and how to get the ideological opposition groups out of the way. We see the Obama thing as essentially a setback in fighting for genuine reform. Obama says he is trying to figure out a way to provide health care for all, and the industry turns around and raises rates to make it unaffordable. We've done massive protests in an effort to get insurers to get rate increases rolled back. The problem is that Obama and the Democrats are bipartisan, but the right wing is not.